Talked to police because you witnessed a crime, were the victim of a crime, or the alleged perpetrator of a crime or because the police told you that you must move along? Refused Stayed one or more nights in a holding cell, jail or prison or juvenile detention, whether that was a short-term stay like the drunk tank, a longer stay for a more serious offence, or anything in between? Refused Have you been attacked or beaten up since you’ve become homeless? Y N Refused Have you threatened to or tried to harm yourself or anyone else in the last year? Y N Refused Do you have any legal stuff going on right now that may result in you being locked up, having to pay fines, or that make it more difficult to rent a place to live? Y N Refused Were you ever incarcerated when younger than age 18? Y N Refused Does anybody force or trick you to do things that you do not want to do? Y N Refused Do you ever do things that may be considered to be risky like exchange sex for money, run drugs for someone, have unprotected sex with someone you don’t know, share a needle, or anything like that? Y N Refused C. Socialization & Daily Functioning Is there any person, past landlord, business, bookie, dealer, or government group like the CRA that thinks you owe them money? Y N Refused Do you get any money from the government, an inheritance, an allowance, working under the table, a regular job, or anything like that? (get from #14 above) Y N Do you have planned activities, other than just surviving, that make you feel happy and fulfilled? Y N Refused Are you currently able to take care of basic needs like bathing, changing clothes, using a restroom, getting food and clean water and other things like that? Y N Refused Is your current lack of stable housing… Because you ran away from your family home, a group home or a foster home? Y N Refused Because of a difference in religious or cultural beliefs from your parents, guardians or caregivers? Y N Refused Because your family or friends caused you to become homeless? Y N Refused Because of conflicts over gender identity or sexual orientation? Y N Refused Because of violence at home between family members? Y N Refused Because of an unhealthy or abusive relationship, at home or elsewhere? Y N Refused D. Wellness Have you ever had to leave an apartment, shelter program, or other place you were Y N Refused
staying because of your physical health? Do you have any chronic health issues with your liver, kidneys, stomach, lungs or heart? Y N Refused Do you have any physical disabilities that would limit the type of housing you could access, or would make it hard to live independently because you’d need help? Y N Refused When you are sick or not feeling well, do you avoid getting help? Y N Refused Are you currently pregnant, have you ever been pregnant or have you ever gotten someone pregnant? Y N N/A or Refused Has your drinking or drug use led you to being kicked out of an apartment or program where you were staying in the past? Y N Refused Will drinking or drug use make it difficult for you to stay housed or afford your housing? Y N Refused If you’ve ever used marijuana, did you ever try it at age 12 or younger? Y N Refused Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of: A mental health issue or concern? Y N Refused A past head injury? Y N Refused A learning disability, developmental disability, or other impairment? Y N Refused Do you have any mental health or brain issues that would make it hard for you to live independently because you’d need help? Y N Refused Are there any medications that a doctor said you should be taking that, for whatever reason, you are not taking? Y N Refused Are there any medications like painkillers that you don’t take the way the doctor prescribed or where you sell the medication? Y N Refused Follow-Up Questions On a regular day, where is it easiest to find you and what time of day is easiest to do so? place: time: : or Morning/Afternoon/Evening/Night Is there a phone number and/or email where someone can safely get in touch with you or leave you a message? phone: ( ) - email: Ok, now I’d like to take your picture so that it is easier to find you and confirm your identity in the future. May I do so? Yes No Refused