Street drinking in Hounslow [PDF]

Appendix 2Appendix 2 - Street Drinkers QuestionnaireDate & Time: Location: Weather: _____Personal DetailsGender: M F Age:Sexual Orientation: Gay/Lesbian Bi-sexual Heterosexual Not StatedRace:Nationality:Support NeedsMental Health Children Learning Difficulty Pet (Specify)Physical Health Pregnant Couple Other ______Substance UsePrimary: How long using? How much? ____________Secondary: How supporting? ______AccommodationBorough of origin: How long here? ___________________Rough Sleeper Private Rented Hostel (Specify) ______Hidden Homeless Squat Other (Specify) ______Tenancy: Licence Short hold AssuredIf homeless, how long? Under 6 months 6 months - 1 year 1 - 2 years2 - 5 years over 5 yearsIf housed, do you have problems with any of the following?Give DetailsBills: Council Tax Gas Rent arrearsElectricity Housing Benefit Other (Specify) ______Other: Cooking Lack of furniture Lack of Support CleaningLonelinessPage 39