Homeless is having no permanent residency, this can be temporary accommodation, sofa surfing or rough sleeping. We want the views of anybody currently classed as homeless or who has been in the past.

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1. How long have you been homeless? or were homeless in the past?

2. Do you have a GP/If so which practice?

3. Do you suffer from mental ill health?

Yes
No

4. Have you received a diagnosis? If yes use the space below to tell us more

Yes
No

5. If yes, were you supported with your diagnosis?

Yes
No

6. Do you have a care plan going forward

Yes
No

7. Are you on any prescribed medication?

Yes
No

8. Do you manage to get this regularly?

Yes
No

9. Are you supported by any services?

Yes
No

10. Which services are supporting you /what has been their impact?

11. Do you have any physical health conditions?

Yes
No

12. Do you have any addictions?

Yes
No

13. Are you aware of any contributing factors to you becoming homeless if so please select below

Financial Status
Drug/alcohol misuse
Bereavement

Relationship breakdown
Mental ill health

Domestic violence
Other

14. What do you think may help you access suitable accommodation?

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