Baseline - U-turn

Program

Service Provider

Where was the Baseline captured?

Baseline captured by

Who captured the baseline?

Baseline captured on

Client Name

Does the client currently have an ID document?

1. How long have you lived on the street?

Time spent living on the street

When was the first night that you spent on the street?

2. What type of accommodation do you usually sleep in?

Primary accommodation

Name of Shelter

other accommodation

Street address / local landmark

City

Suburb

Other Suburb

3. Why are you living on the streets?

Tick all that apply

Behavioural health / mental health issue

Came out of prison with nowhere to go

Circumstance / personal problems

Disability

Drinking or drug problem

Gangsterism

I have nowhere to go

Living on Street by Choice

Lost house/ Repossessed

No family support/Parents died

Prefer not to say why living on street

Ran away from home

Unemployed / lost job / no income

Violence at home

Other (Please specify)

Please specify other reason, why living on the streets

4. What are your main sources of income

Tick all that apply

AD hoc employment

Donations at traffic light

Income from residents or households

Income from tourists

Employment (full/part-time)

NGOs or EPWP

Friends/family

Government grant

Park Cars

Recycling

Selling drugs

Sex Worker

Work for informal trader

Prefer not to say (income)

Other sources of income

Other main source of income

5. Drug use (excluding alcohol and tobacco)

Have you used drugs in the last month?

1st Drug of Choice

Other First Drug of Choice

Additional drugs of choice

Amphetamine

Cocaine

Cannabis

Hallucinogens

Inhalants

Opioids

Sedatives

None

Other

Other Drug of Choice

Have you ever been in treatment/ drug rehab?

6. Alcohol use

Have you drunk alcohol in the last month

Do you have 6 drinks or more on 1 day?

7. What is the last standard/ grade you passed at school?

Highest level of education

8. Would you like any assistance to leave the streets?

Assistance to leave the street?

Other Assistance

Confidentiality Statement Signed

Any other relevant information given

Recommended next steps?

U-turn Contact Id

On submission, a U-turn Baseline and a Service Delivery is created for the Programme you selected above