Full Name
*
Date of Birth
*
Contact Number
*
Client Home Location
City and Postcode
*
State
*
Type of housing
*
House
Apartment
Residential care facility
Supported Independent Living (SIL) House
Other
If selected other, please specify
Is there parking available close by?
*
Yes
No
Can you see the house from the street?
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Yes
No
How would you like us to enter?
*
Will someone be able to open the door?
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Yes
No
Is there mobile phone reception at your house?
*
Yes
No
Who else lives at this address (people or animals)?
*
Will they be home when we visit?
*
If no one is home when we visit, who is the best person to contact?
*
Does anyone at home take drugs or excessively drink alcohol?
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Yes
No
Are there any weapons at home?
*
Yes
No
If yes, please elaborate.
Does yourself or anyone present have a history of violent behaviour? (if yes, please give details)
*
Does anyone currently have a contagious illness/COVID 19?
*
Yes
No
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