Supporting People GNME
Date of Completion (DD/MM/YY):
Agency/Department Name:
(office use only)
Contact No:
First 3 Letters of Surname:
Date of Birth (DD/MM/YY):
Age Group:
16-17
18-24
25-39
40-59
60+
Gender:
Male
Female
Other
Other
How many over 16's in the houshold:
0
1
2
3
4
5+
How many under 16's in the houshold:
0
1
2
3
4
5+
Which Local Authority are do you currently live in?
Blaenau-Gwent
Caerphilly
Monmouthshire
Newport
Torfaen
Other, please state
Other
Where do you currently live?
Armed Forces Accommodation
Bed & Breakfast
Group Home/Shared House
Hospital - Medical
Living with family
Owner Occupier
Prison
Sheltered Accomodation
Staying with friends/sofa surfing
Residential care/nursing home
Adult Placement Scheme/shared lives
Children's home/foster care
Hostel
Hospital - Psychiatric
Long term/secure tenancy
Private Rented
Refuge (for Domestic Abuse)
Sleeping Rough
Supported Lodgings
Temporary rented (Private Sector Lease)
Other
Other
Sleeping Rough - Where did you live before:
Armed Forces Accommodation
Bed & Breakfast
Group Home/Shared House
Hospital - Medical
Living with family
Owner Occupier
Prison
Sheltered Accomodation
Staying with friends/sofa surfing
Residential care/nursing home
Adult Placement Scheme/shared lives
Children's home/foster care
Hostel
Hospital - Psychiatric
Long term/secure tenancy
Private Rented
Refuge (for Domestic Abuse)
Sleeping Rough
Supported Lodgings
Temporary rented (Private Sector Lease)
Other
Other
Do you currently have:
Social Worker
Community Mental Health Nurse
Probation Officer
Youth Offending Team/Service Worker
Other
Other
Have you previously been in care:
Yes
No
Area of need:
1
2
3
4
5
6
7
8
9
10
E1 Domestic Abuse/violent relationship
E2 Learning Disability
E3 Mental Health Issues
E4 Alcohol Dependancy
E5 Drug Dependancy
E6 Refugee
E7 Physical Disability
E8 Young & Vulnerable
E9 Ex-Offender/Criminal Justice
E10 Homeless/potentially homeless
E11 Chronic Illness
E12 Vulnerable Single Parent
E13 Vulnerable Two Parent Family
E14 Older Person
E15 Frail Person
E16 Visual Impairment/Blind
E16 Hearing Impairment/Deaf
E17 HIV & Aids
Main Support Need:
E1 Domestic Abuse/Violent Relationship
E2 Learning Disability
E3 Mental Health Issues
E4 Alcohol Dependancy
E5 Drug Dependancy
E6 Refugee
E7 Physical Disability
E8 Young & Vulnerable
E9 Ex Offender/Criminal Justice
E10 Homelessness
E11 Chronic Illness
E12 Vulnerable Single Parent
E13 Vulnerable Two Parent Family
E14 Older Person
E15 Frail Person
E16 Visual Impairment/Blind
E16 Hearing Impairment/Deaf
E17 HIV & AIDS
Next Support Need:
E1 Domestic Abuse/Violent Relationship
E2 Learning Disability
E3 Mental Health Issues
E4 Alcohol Dependancy
E5 Drug Dependancy
E6 Refugee
E7 Physical Disability
E8 Young & Vulnerable
E9 Ex Offender/Criminal Justice
E10 Homelessness
E11 Chronic Illness
E12 Vulnerable Single Parent
E13 Vulnerable Two Parent Family
E14 Older Person
E15 Frail Person
E16 Visual Impairment/Blind
E16 Hearing Impairment/Deaf
E17 HIV & AIDS
What type of accomodation do you want/think you need:
Now
Longer Term
Housing & Support are satisfactory (no change in next 12 months)
Ordinary housing with visiting/floating support (flat/house)
Ordinary housing with no support (flat/house)
Sheltered accommodation
Extra Care sheltered for frail elderly
Temporary specialist supported housing
Special detox facility
Hostel
Refuge for people escaping domestic abuse
Residential care/nursing home
Shared house, not 24 hour staff support
Shared house with 24 hour on-site staff
Self contained within the same house
Need to return home
Need to return home with aids/adaptations
Don't know
Other
Other
Housing Related Support Needs:
Receiving
Need
Advice, advocacy and liaison with other agencies
Assistive technology e.g. tele-care, tele-health etc
Community alarm services
Emotional support/counselling
Arranging services
Social skills/confidence
Domestic and practical living skills
Personal safety/security
Social contacts and activities
Finding other accommodation
Access to services
Managing behaviour/attitude
Setting up/maintaining a home
Benefit claims
Budgeting/managing finances/debt management
Monitoring health and well-being
Peer support and befriending
Other
Other
Mental Health Problems:
Anxiety/Depression
Alzheimer's/Dementia
Bi-Polar/Manic Depression
No mental health issues
Personality Disorder
Schizophrenia
Prefer not to say
Other
Other
Additional Information:
BME
Cultural/Religious
English as 2nd language
Gender Identity
Gypsy/Traveller
Handy-person Service
Forced Marriage
Honour Based Violence
Literacy
Parenting/Children
Pregnancy
Sexual Explotation
Sexual Orientation/Trafficking
Women-only Provision
Other
Other
Length of Support:
Up to 6 months
6-12 months
12-18 months
Over 18 months
Permanent
Don't know
Access to Health Services - services not registered with but needed:
Doctor
Community Mental Health Team
Dentist
Health Visitor
Opticians
Specialist Substance Misuse Services
Other
Other
Problems Accessing Health Services:
Attitude of staff
Availability of services
Confidence/self esteem
Have not tried to get Dr
Lack of support
Lack of interpreters
Making appointments
Opening hours
Personal appearance
Travelling to services
Refused Registration
Other
Other
Ethnicity:
Bangladeshi
British Born Asian
Indian
Pakistani
African
African Somali
Black British
Caribbean
Arab
Chinese
Gypsy/Traveller
Vietnamese
Yemeni
British
Welsh
English
Irish
Scottish
East European
Other European
White & Asian
White & Black African
White & Black Caribbean
Prefer not to say
Other
Other
Sexual Orientation:
Bi-Sexual
Gay/Lesbian
Heterosexual
Prefer not to say
Other preferred description
Other
What is you first language:
Religion or Belief:
Atheist
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
None
Rastafarian
Sikh
Prefer not to say
Other
Other
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