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Drug Abuse and Homelessness
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
What is your gender?
Male
Female
Other
2
How old are you?
>18
19-25
26-30
31-40
40-65
65<
3
Have you ever been addicted to a substance?
yes
no
4
What substance where you addicted to?
Alcohol
Opioids
Cociane
Methamphetamines
I have never been addicted to a substance
Other
5
How old were you when you started using this substance?
>18
19-25
26-30
31-40
41-50
51-65
65<
I have never been addicted to a substance
6
Have you ever experienced homelessness?
yes
no
7
How old where you when you became homeless?
>18
18-25
26-30
31-40
41-50
51-65
65<
I have never experienced homelessness
8
How long where you homeless?
less than 1 week
1-2 weeks
2-4 weeks
1-3 months
4-6 months
6 months - 1 year
1 year<
I have never experienced homelessness
9
Did you ever stay in a shelter?
yes
no
I have never experienced homelessness
10
Did you feel safe in the shelter?
yes
no
I have been homeless but never stayed in a shelter
I have never experienced homelessness
11
Did the shelter offer mental health care?
yes
no
I have been homeless but never stayed in a shelter
I have never experienced homelessness
12
Did the shelter offer child care?
yes
no
I have been homeless but have never stayed in a shelter
I have never experienced homelessness
13
Did you feel you were treated with respect while staying in the shelter?
yes
no
I have been homeless but never stayed in a shelter
I have never experienced homelessness
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