Untitled Document<\/title><br \/>\n<\/head><\/p>\n<p><body><br \/>\n <\/p>\n<p> <\/p>\n<p> <\/p>\n<p> <\/p>\n<p> <\/p>\n<p> <\/p>\n<p> <\/p>\n<p><\/p>\n<form action=\"https:\/\/www.salesforce.com\/servlet\/servlet.WebToCase?encoding=UTF-8\" method=\"POST\">\n <input type=hidden name=\"orgid\" value=\"00DD0000000nG0e\"><br \/>\n <input type=hidden name=\"retURL\" value=\"http:\/\/londonfriend.org.uk\/2012\/2012\/antidote-web-to-top\"><\/p>\n<p> <br \/>\n <br \/>\n <br \/>\n <br \/>\n <br \/>\n <br \/>\n <br \/>\n<input id=\"email\" name=\"email\" type=\"hidden\" value=\"sophia@londonfriend.org.uk\"><br \/>\n<br \/>\n<input type=hidden id=\"00ND0000004vRE4\" maxlength=\"50\" name=\"00ND0000004vRE4\" size=\"20\" value = \"[s2Get user_field=\"full_name\" \/]\"><\/p>\n<p><a href=\"http:\/\/londonfriend.org.uk\/2012\/2012\/members-area\/\">Back to Members Area<\/a><\/p>\n<p> <\/p>\n<h1>Antidote TOP Form Submission<\/h1>\n<p> <\/p>\n<table width=\"100%\" border=\"1\">\n<tr>\n<td>\n <br \/>\n <strong>First Name (or Client Reference if known): <\/strong><input id=\"00ND0000005L3O0\" maxlength=\"7\" name=\"00ND0000005L3O0\" size=\"20\" type=\"text\" \/>\n <\/td>\n<\/tr>\n<tr>\n<td>\n <br \/>\n <strong>Surname (or Client Initials if Client Ref is known):<\/strong><input id=\"00ND0000005LjZw\" maxlength=\"3\" name=\"00ND0000005LjZw\" size=\"20\" type=\"text\" \/>\n <\/td>\n<tr>\n<td><strong>TOP Date (dd\/mm\/yy):<\/strong><span class=\"dateInput dateOnlyInput\"><br \/>\n <input id=\"00ND0000004Awui\" name=\"00ND0000004Awui\" size=\"12\" type=\"text\" \/><br \/>\n <\/span><\/td>\n<td>\n<\/td>\n<\/tr>\n<td><strong>Treatment Stage:<\/strong><br \/>\n <select id=\"00ND0000004AvZI\" name=\"00ND0000004AvZI\" title=\"Treatment Stage\"><option value=\"\">--None--<\/option><option value=\"Modality Start\">Modality Start<\/option><option value=\"Care plan review\">Care plan review<\/option><option value=\"Discharge\">Discharge<\/option><\/select><\/td>\n<\/tr>\n<td><strong>Attendance:<\/strong><br \/>\n <select id=\"00ND0000005KXwu\" name=\"00ND0000005KXwu\" title=\"Attendance\"><option value=\"\">--None--<\/option><option value=\"Attended\">Attended<\/option><option value=\"Did not attend\">Did not attend<\/option><option value=\"Cancelled - client\">Cancelled - client<\/option><option value=\"Cancelled - LF\">Cancelled - LF<\/option><option value=\"Not applicable\">Not applicable<\/option><\/select><\/td>\n<\/tr>\n<td><strong>Session Type:<\/strong><br \/>\n <select id=\"00ND0000005KXvv\" name=\"00ND0000005KXvv\" title=\"Session Type\"><option value=\"\">--None--<\/option><option value=\"Antidote drop-in\">Antidote drop-in<\/option><option value=\"Keywork (Tier 3)\">Keywork (Tier 3)<\/option><\/select><\/td>\n<\/tr>\n<td><strong>Location:<\/strong><br \/>\n <select id=\"00ND0000005KXue\" name=\"00ND0000005KXue\" title=\"Location\"><option value=\"\">--None--<\/option><option value=\"LF Caledonian Road\">LF Caledonian Road<\/option><option value=\"Wardour Street\">Wardour Street<\/option><option value=\"CDC\">CDC<\/option><option value=\"Code\">Code<\/option><option value=\"cliniQ\">cliniQ<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td>\n <strong>HIV Advice & Information given?: <\/strong><input id=\"00ND0000005OCcr\" name=\"00ND0000005OCcr\" type=\"checkbox\" value=\"1\" \/>\n <\/td>\n<\/tr>\n<\/table>\n<table width=\"100%\" border=\"1\">\n<tr>\n<td colspan=\"5\"><strong>Section 1: Substance use (Please use NA only if information is not disclosed or not answered.)<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"40%\"> <\/td>\n<td width=\"15%\">Week 4<\/td>\n<td width=\"15%\">Week 3<\/td>\n<td width=\"15%\">Week 2<\/td>\n<td width=\"15%\">Week 1<\/td>\n<\/tr>\n<tr>\n<td>Alcohol Average (units\/day):<br \/>\n <input id=\"00ND0000004AvZR\" name=\"00ND0000004AvZR\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004AvZb\" name=\"00ND0000004AvZb\" title=\"Alcohol Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004AvZg\" name=\"00ND0000004AvZg\" title=\"Alcohol Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004AvZq\" name=\"00ND0000004AvZq\" title=\"Alcohol Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004AvZv\" name=\"00ND0000004AvZv\" title=\"Alcohol Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Opiates Average (g\/day):<br \/>\n <input id=\"00ND0000004B13P\" name=\"00ND0000004B13P\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B13j\" name=\"00ND0000004B13j\" title=\"Opiates Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13e\" name=\"00ND0000004B13e\" title=\"Opiates Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13Z\" name=\"00ND0000004B13Z\" title=\"Opiates Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13U\" name=\"00ND0000004B13U\" title=\"Opiates Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Crack Average (g\/day):<br \/>\n <input id=\"00ND0000004B16e\" name=\"00ND0000004B16e\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B143\" name=\"00ND0000004B143\" title=\"Crack Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13y\" name=\"00ND0000004B13y\" title=\"Crack Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13t\" name=\"00ND0000004B13t\" title=\"Crack Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13o\" name=\"00ND0000004B13o\" title=\"Crack Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Cocaine Average (g\/day):<br \/>\n <input id=\"00ND0000004B17H\" name=\"00ND0000004B17H\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B14N\" name=\"00ND0000004B14N\" title=\"Cocaine Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14I\" name=\"00ND0000004B14I\" title=\"Cocaine Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14D\" name=\"00ND0000004B14D\" title=\"Cocaine Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B148\" name=\"00ND0000004B148\" title=\"Cocaine Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Amphetamines Average (g\/day):<br \/>\n <input id=\"00ND0000004B16f\" name=\"00ND0000004B16f\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B14h\" name=\"00ND0000004B14h\" title=\"Amphetamines Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14c\" name=\"00ND0000004B14c\" title=\"Amphetamines Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14X\" name=\"00ND0000004B14X\" title=\"Amphetamines Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14S\" name=\"00ND0000004B14S\" title=\"Amphetamines Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Cannabis Average (spliff\/day):<br \/>\n <input id=\"00ND0000004B17M\" name=\"00ND0000004B17M\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B14w\" name=\"00ND0000004B14w\" title=\"Cannabis Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14r\" name=\"00ND0000004B14r\" title=\"Cannabis Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14T\" name=\"00ND0000004B14T\" title=\"Cannabis Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14m\" name=\"00ND0000004B14m\" title=\"Cannabis Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td>Other Problem Substance Average (g\/day):<br \/>\n <input id=\"00ND0000004B17R\" name=\"00ND0000004B17R\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B13u\" name=\"00ND0000004B13u\" title=\"OPS Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B156\" name=\"00ND0000004B156\" title=\"OPS Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B151\" name=\"00ND0000004B151\" title=\"OPS Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14i\" name=\"00ND0000004B14i\" title=\"OPS Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Other Problem Substance Name: <\/td>\n<td colspan=\"2\"><textarea id=\"00ND0000004B17W\" name=\"00ND0000004B17W\" type=\"text\" wrap=\"soft\"><\/textarea><\/td>\n<\/tr>\n<tr>\n<td colspan=\"5\"><strong>Section 2: Injecting risk behaviour (Please use NA only if information is not disclosed or not answered.)<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"40%\"> <\/td>\n<td width=\"15%\">Week 4<\/td>\n<td width=\"15%\">Week 3<\/td>\n<td width=\"15%\">Week 2<\/td>\n<td width=\"15%\">Week 1<\/td>\n<\/tr>\n<tr>\n<td>Injected<\/td>\n<td><select id=\"00ND0000004B15C\" name=\"00ND0000004B15C\" title=\"Injected Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15L\" name=\"00ND0000004B15L\" title=\"Injected Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15G\" name=\"00ND0000004B15G\" title=\"Injected Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15B\" name=\"00ND0000004B15B\" title=\"Injected Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Inject with needle or syringe used by someone else?<\/td>\n<td ><input id=\"00ND0000004B16U\" name=\"00ND0000004B16U\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Inject using a spoon, water or filter used by someone else?<\/td>\n<td><input id=\"00ND0000004B17b\" name=\"00ND0000004B17b\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"5\"><strong>Section 3: Crime (Please use NA only if information is not disclosed or not answered.)<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"40%\"> <\/td>\n<td width=\"15%\">Week 4<\/td>\n<td width=\"15%\">Week 3<\/td>\n<td width=\"15%\">Week 2<\/td>\n<td width=\"15%\">Week 1<\/td>\n<\/tr>\n<tr>\n<td>Shoplifting<\/td>\n<td><select id=\"00ND0000004B14E\" name=\"00ND0000004B14E\" title=\"Shoplifting Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B16E\" name=\"00ND0000004B16E\" title=\"Shoplifting Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B169\" name=\"00ND0000004B169\" title=\"Shoplifting Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B164\" name=\"00ND0000004B164\" title=\"Shoplifting Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Drug Selling<\/td>\n<td><select id=\"00ND0000004B14U\" name=\"00ND0000004B14U\" title=\"Drug Selling Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15a\" name=\"00ND0000004B15a\" title=\"Drug Selling Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15V\" name=\"00ND0000004B15V\" title=\"Drug Selling Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15Q\" name=\"00ND0000004B15Q\" title=\"Drug Selling Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Theft Vehicle: <\/td>\n<td><input id=\"00ND0000004B17g\" name=\"00ND0000004B17g\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Other Property Theft: <\/td>\n<td><input id=\"00ND0000004B17l\" name=\"00ND0000004B17l\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Fraud etc: <\/td>\n<td><input id=\"00ND0000004B17m\" name=\"00ND0000004B17m\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Committing assault or violence: <\/td>\n<td><input id=\"00ND0000004B17q\" name=\"00ND0000004B17q\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"5\"><strong>Section 4: Health and social functioning (Please use NA only if information is not disclosed or not answered.)<\/strong><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Psychological Health Status: <\/td>\n<td><select id=\"00ND0000004B17h\" name=\"00ND0000004B17h\" title=\"Psychological Health Status\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td width=\"40%\"> <\/td>\n<td width=\"15%\">Week 4<\/td>\n<td width=\"15%\">Week 3<\/td>\n<td width=\"15%\">Week 2<\/td>\n<td width=\"15%\">Week 1<\/td>\n<\/tr>\n<tr>\n<td> Paid Work <\/td>\n<td><select id=\"00ND0000004B15u\" name=\"00ND0000004B15u\" title=\"Paid Work Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15p\" name=\"00ND0000004B15p\" title=\"Paid Work Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15k\" name=\"00ND0000004B15k\" title=\"Paid Work Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15f\" name=\"00ND0000004B15f\" title=\"Paid Work Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Attended College or School<\/td>\n<td><select id=\"00ND0000004B16T\" name=\"00ND0000004B16T\" title=\"Attended College or School Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B16O\" name=\"00ND0000004B16O\" title=\"Attended College or School Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B16J\" name=\"00ND0000004B16J\" title=\"Attended College or School Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15z\" name=\"00ND0000004B15z\" title=\"Attended College or School Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Physical Health Status: <\/td>\n<td><select id=\"00ND0000004B17v\" name=\"00ND0000004B17v\" title=\"Physical Health Status\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\">Acute Housing Problem: <\/td>\n<td><input id=\"00ND0000004B185\" name=\"00ND0000004B185\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> At Risk of Eviction: <\/td>\n<td><input id=\"00ND0000004B18A\" name=\"00ND0000004B18A\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\">Quality of Life: <\/td>\n<td><select id=\"00ND0000004B180\" name=\"00ND0000004B180\" title=\"Quality of Life\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><\/select><\/td>\n<\/tr>\n<p> <\/p>\n<p> <input type=\"hidden\" id=\"recordType\" name=\"recordType\" value=\"012D0000000NGCH\" \/><br \/>\n <\/select><\/p>\n<\/table>\n<p> <input type=\"hidden\" id=\"external\" name=\"external\" value=\"1\" \/><br \/>\n <input type=\"submit\" name=\"submit\"><br \/>\n<\/form>\n<p><\/body><br \/>\n<\/html><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Untitled Document Back to Members Area Antidote TOP Form Submission First Name (or Client Reference if known): Surname (or Client Initials if Client Ref is known): TOP Date (dd\/mm\/yy): Treatment Stage: –None–Modality StartCare plan reviewDischarge Attendance: –None–AttendedDid not … <a href=\"http:\/\/londonfriend.org.uk\/2012\/antidote-web-to-top\/\">Continue reading <span class=\"meta-nav\">→<\/span><\/a><\/p>\n","protected":false},"author":7,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":["post-2128","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/pages\/2128"}],"collection":[{"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/comments?post=2128"}],"version-history":[{"count":35,"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/pages\/2128\/revisions"}],"predecessor-version":[{"id":2912,"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/pages\/2128\/revisions\/2912"}],"wp:attachment":[{"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/media?parent=2128"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}

{"id":2128,"date":"2013-04-09T13:47:02","date_gmt":"2013-04-09T12:47:02","guid":{"rendered":"http:\/\/londonfriend.org.uk\/?page_id=2128"},"modified":"2013-11-04T15:04:44","modified_gmt":"2013-11-04T14:04:44","slug":"antidote-web-to-top","status":"publish","type":"page","link":"http:\/\/londonfriend.org.uk\/2012\/antidote-web-to-top\/","title":{"rendered":"Antidote TOP form submission"},"content":{"rendered":"

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\nUntitled Document<\/title><br \/>\n<\/head><\/p>\n<p><body><br \/>\n <\/p>\n<p> <\/p>\n<p> <\/p>\n<p> <\/p>\n<p> <\/p>\n<p> <\/p>\n<p> <\/p>\n<p><\/p>\n<form action=\"https:\/\/www.salesforce.com\/servlet\/servlet.WebToCase?encoding=UTF-8\" method=\"POST\">\n <input type=hidden name=\"orgid\" value=\"00DD0000000nG0e\"><br \/>\n <input type=hidden name=\"retURL\" value=\"http:\/\/londonfriend.org.uk\/2012\/2012\/antidote-web-to-top\"><\/p>\n<p> <br \/>\n <br \/>\n <br \/>\n <br \/>\n <br \/>\n <br \/>\n <br \/>\n<input id=\"email\" name=\"email\" type=\"hidden\" value=\"sophia@londonfriend.org.uk\"><br \/>\n<br \/>\n<input type=hidden id=\"00ND0000004vRE4\" maxlength=\"50\" name=\"00ND0000004vRE4\" size=\"20\" value = \"[s2Get user_field=\"full_name\" \/]\"><\/p>\n<p><a href=\"http:\/\/londonfriend.org.uk\/2012\/2012\/members-area\/\">Back to Members Area<\/a><\/p>\n<p> <\/p>\n<h1>Antidote TOP Form Submission<\/h1>\n<p> <\/p>\n<table width=\"100%\" border=\"1\">\n<tr>\n<td>\n <br \/>\n <strong>First Name (or Client Reference if known): <\/strong><input id=\"00ND0000005L3O0\" maxlength=\"7\" name=\"00ND0000005L3O0\" size=\"20\" type=\"text\" \/>\n <\/td>\n<\/tr>\n<tr>\n<td>\n <br \/>\n <strong>Surname (or Client Initials if Client Ref is known):<\/strong><input id=\"00ND0000005LjZw\" maxlength=\"3\" name=\"00ND0000005LjZw\" size=\"20\" type=\"text\" \/>\n <\/td>\n<tr>\n<td><strong>TOP Date (dd\/mm\/yy):<\/strong><span class=\"dateInput dateOnlyInput\"><br \/>\n <input id=\"00ND0000004Awui\" name=\"00ND0000004Awui\" size=\"12\" type=\"text\" \/><br \/>\n <\/span><\/td>\n<td>\n<\/td>\n<\/tr>\n<td><strong>Treatment Stage:<\/strong><br \/>\n <select id=\"00ND0000004AvZI\" name=\"00ND0000004AvZI\" title=\"Treatment Stage\"><option value=\"\">--None--<\/option><option value=\"Modality Start\">Modality Start<\/option><option value=\"Care plan review\">Care plan review<\/option><option value=\"Discharge\">Discharge<\/option><\/select><\/td>\n<\/tr>\n<td><strong>Attendance:<\/strong><br \/>\n <select id=\"00ND0000005KXwu\" name=\"00ND0000005KXwu\" title=\"Attendance\"><option value=\"\">--None--<\/option><option value=\"Attended\">Attended<\/option><option value=\"Did not attend\">Did not attend<\/option><option value=\"Cancelled - client\">Cancelled - client<\/option><option value=\"Cancelled - LF\">Cancelled - LF<\/option><option value=\"Not applicable\">Not applicable<\/option><\/select><\/td>\n<\/tr>\n<td><strong>Session Type:<\/strong><br \/>\n <select id=\"00ND0000005KXvv\" name=\"00ND0000005KXvv\" title=\"Session Type\"><option value=\"\">--None--<\/option><option value=\"Antidote drop-in\">Antidote drop-in<\/option><option value=\"Keywork (Tier 3)\">Keywork (Tier 3)<\/option><\/select><\/td>\n<\/tr>\n<td><strong>Location:<\/strong><br \/>\n <select id=\"00ND0000005KXue\" name=\"00ND0000005KXue\" title=\"Location\"><option value=\"\">--None--<\/option><option value=\"LF Caledonian Road\">LF Caledonian Road<\/option><option value=\"Wardour Street\">Wardour Street<\/option><option value=\"CDC\">CDC<\/option><option value=\"Code\">Code<\/option><option value=\"cliniQ\">cliniQ<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td>\n <strong>HIV Advice & Information given?: <\/strong><input id=\"00ND0000005OCcr\" name=\"00ND0000005OCcr\" type=\"checkbox\" value=\"1\" \/>\n <\/td>\n<\/tr>\n<\/table>\n<table width=\"100%\" border=\"1\">\n<tr>\n<td colspan=\"5\"><strong>Section 1: Substance use (Please use NA only if information is not disclosed or not answered.)<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"40%\"> <\/td>\n<td width=\"15%\">Week 4<\/td>\n<td width=\"15%\">Week 3<\/td>\n<td width=\"15%\">Week 2<\/td>\n<td width=\"15%\">Week 1<\/td>\n<\/tr>\n<tr>\n<td>Alcohol Average (units\/day):<br \/>\n <input id=\"00ND0000004AvZR\" name=\"00ND0000004AvZR\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004AvZb\" name=\"00ND0000004AvZb\" title=\"Alcohol Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004AvZg\" name=\"00ND0000004AvZg\" title=\"Alcohol Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004AvZq\" name=\"00ND0000004AvZq\" title=\"Alcohol Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004AvZv\" name=\"00ND0000004AvZv\" title=\"Alcohol Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Opiates Average (g\/day):<br \/>\n <input id=\"00ND0000004B13P\" name=\"00ND0000004B13P\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B13j\" name=\"00ND0000004B13j\" title=\"Opiates Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13e\" name=\"00ND0000004B13e\" title=\"Opiates Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13Z\" name=\"00ND0000004B13Z\" title=\"Opiates Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13U\" name=\"00ND0000004B13U\" title=\"Opiates Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Crack Average (g\/day):<br \/>\n <input id=\"00ND0000004B16e\" name=\"00ND0000004B16e\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B143\" name=\"00ND0000004B143\" title=\"Crack Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13y\" name=\"00ND0000004B13y\" title=\"Crack Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13t\" name=\"00ND0000004B13t\" title=\"Crack Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B13o\" name=\"00ND0000004B13o\" title=\"Crack Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Cocaine Average (g\/day):<br \/>\n <input id=\"00ND0000004B17H\" name=\"00ND0000004B17H\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B14N\" name=\"00ND0000004B14N\" title=\"Cocaine Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14I\" name=\"00ND0000004B14I\" title=\"Cocaine Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14D\" name=\"00ND0000004B14D\" title=\"Cocaine Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B148\" name=\"00ND0000004B148\" title=\"Cocaine Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Amphetamines Average (g\/day):<br \/>\n <input id=\"00ND0000004B16f\" name=\"00ND0000004B16f\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B14h\" name=\"00ND0000004B14h\" title=\"Amphetamines Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14c\" name=\"00ND0000004B14c\" title=\"Amphetamines Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14X\" name=\"00ND0000004B14X\" title=\"Amphetamines Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14S\" name=\"00ND0000004B14S\" title=\"Amphetamines Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Cannabis Average (spliff\/day):<br \/>\n <input id=\"00ND0000004B17M\" name=\"00ND0000004B17M\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B14w\" name=\"00ND0000004B14w\" title=\"Cannabis Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14r\" name=\"00ND0000004B14r\" title=\"Cannabis Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14T\" name=\"00ND0000004B14T\" title=\"Cannabis Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14m\" name=\"00ND0000004B14m\" title=\"Cannabis Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td>Other Problem Substance Average (g\/day):<br \/>\n <input id=\"00ND0000004B17R\" name=\"00ND0000004B17R\" size=\"20\" type=\"text\" \/>\n <\/td>\n<td><select id=\"00ND0000004B13u\" name=\"00ND0000004B13u\" title=\"OPS Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B156\" name=\"00ND0000004B156\" title=\"OPS Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B151\" name=\"00ND0000004B151\" title=\"OPS Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B14i\" name=\"00ND0000004B14i\" title=\"OPS Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Other Problem Substance Name: <\/td>\n<td colspan=\"2\"><textarea id=\"00ND0000004B17W\" name=\"00ND0000004B17W\" type=\"text\" wrap=\"soft\"><\/textarea><\/td>\n<\/tr>\n<tr>\n<td colspan=\"5\"><strong>Section 2: Injecting risk behaviour (Please use NA only if information is not disclosed or not answered.)<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"40%\"> <\/td>\n<td width=\"15%\">Week 4<\/td>\n<td width=\"15%\">Week 3<\/td>\n<td width=\"15%\">Week 2<\/td>\n<td width=\"15%\">Week 1<\/td>\n<\/tr>\n<tr>\n<td>Injected<\/td>\n<td><select id=\"00ND0000004B15C\" name=\"00ND0000004B15C\" title=\"Injected Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15L\" name=\"00ND0000004B15L\" title=\"Injected Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15G\" name=\"00ND0000004B15G\" title=\"Injected Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15B\" name=\"00ND0000004B15B\" title=\"Injected Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Inject with needle or syringe used by someone else?<\/td>\n<td ><input id=\"00ND0000004B16U\" name=\"00ND0000004B16U\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Inject using a spoon, water or filter used by someone else?<\/td>\n<td><input id=\"00ND0000004B17b\" name=\"00ND0000004B17b\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"5\"><strong>Section 3: Crime (Please use NA only if information is not disclosed or not answered.)<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"40%\"> <\/td>\n<td width=\"15%\">Week 4<\/td>\n<td width=\"15%\">Week 3<\/td>\n<td width=\"15%\">Week 2<\/td>\n<td width=\"15%\">Week 1<\/td>\n<\/tr>\n<tr>\n<td>Shoplifting<\/td>\n<td><select id=\"00ND0000004B14E\" name=\"00ND0000004B14E\" title=\"Shoplifting Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B16E\" name=\"00ND0000004B16E\" title=\"Shoplifting Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B169\" name=\"00ND0000004B169\" title=\"Shoplifting Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B164\" name=\"00ND0000004B164\" title=\"Shoplifting Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Drug Selling<\/td>\n<td><select id=\"00ND0000004B14U\" name=\"00ND0000004B14U\" title=\"Drug Selling Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15a\" name=\"00ND0000004B15a\" title=\"Drug Selling Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15V\" name=\"00ND0000004B15V\" title=\"Drug Selling Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15Q\" name=\"00ND0000004B15Q\" title=\"Drug Selling Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Theft Vehicle: <\/td>\n<td><input id=\"00ND0000004B17g\" name=\"00ND0000004B17g\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Other Property Theft: <\/td>\n<td><input id=\"00ND0000004B17l\" name=\"00ND0000004B17l\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Fraud etc: <\/td>\n<td><input id=\"00ND0000004B17m\" name=\"00ND0000004B17m\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Committing assault or violence: <\/td>\n<td><input id=\"00ND0000004B17q\" name=\"00ND0000004B17q\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"5\"><strong>Section 4: Health and social functioning (Please use NA only if information is not disclosed or not answered.)<\/strong><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Psychological Health Status: <\/td>\n<td><select id=\"00ND0000004B17h\" name=\"00ND0000004B17h\" title=\"Psychological Health Status\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td width=\"40%\"> <\/td>\n<td width=\"15%\">Week 4<\/td>\n<td width=\"15%\">Week 3<\/td>\n<td width=\"15%\">Week 2<\/td>\n<td width=\"15%\">Week 1<\/td>\n<\/tr>\n<tr>\n<td> Paid Work <\/td>\n<td><select id=\"00ND0000004B15u\" name=\"00ND0000004B15u\" title=\"Paid Work Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15p\" name=\"00ND0000004B15p\" title=\"Paid Work Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15k\" name=\"00ND0000004B15k\" title=\"Paid Work Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15f\" name=\"00ND0000004B15f\" title=\"Paid Work Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td> Attended College or School<\/td>\n<td><select id=\"00ND0000004B16T\" name=\"00ND0000004B16T\" title=\"Attended College or School Week 4\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B16O\" name=\"00ND0000004B16O\" title=\"Attended College or School Week 3\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B16J\" name=\"00ND0000004B16J\" title=\"Attended College or School Week 2\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<td><select id=\"00ND0000004B15z\" name=\"00ND0000004B15z\" title=\"Attended College or School Week 1\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> Physical Health Status: <\/td>\n<td><select id=\"00ND0000004B17v\" name=\"00ND0000004B17v\" title=\"Physical Health Status\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><\/select><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\">Acute Housing Problem: <\/td>\n<td><input id=\"00ND0000004B185\" name=\"00ND0000004B185\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\"> At Risk of Eviction: <\/td>\n<td><input id=\"00ND0000004B18A\" name=\"00ND0000004B18A\" type=\"checkbox\" value=\"1\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\">Quality of Life: <\/td>\n<td><select id=\"00ND0000004B180\" name=\"00ND0000004B180\" title=\"Quality of Life\"><option value=\"\">--None--<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><\/select><\/td>\n<\/tr>\n<p> <\/p>\n<p> <input type=\"hidden\" id=\"recordType\" name=\"recordType\" value=\"012D0000000NGCH\" \/><br \/>\n <\/select><\/p>\n<\/table>\n<p> <input type=\"hidden\" id=\"external\" name=\"external\" value=\"1\" \/><br \/>\n <input type=\"submit\" name=\"submit\"><br \/>\n<\/form>\n<p><\/body><br \/>\n<\/html><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Untitled Document Back to Members Area Antidote TOP Form Submission First Name (or Client Reference if known): Surname (or Client Initials if Client Ref is known): TOP Date (dd\/mm\/yy): Treatment Stage: –None–Modality StartCare plan reviewDischarge Attendance: –None–AttendedDid not … <a href=\"http:\/\/londonfriend.org.uk\/2012\/antidote-web-to-top\/\">Continue reading <span class=\"meta-nav\">→<\/span><\/a><\/p>\n","protected":false},"author":7,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":["post-2128","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/pages\/2128"}],"collection":[{"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/comments?post=2128"}],"version-history":[{"count":35,"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/pages\/2128\/revisions"}],"predecessor-version":[{"id":2912,"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/pages\/2128\/revisions\/2912"}],"wp:attachment":[{"href":"http:\/\/londonfriend.org.uk\/2012\/wp-json\/wp\/v2\/media?parent=2128"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}