Antidote TOP Form Submission

First name

Surname

TOP Date

Treatment Stage

Attendance

Session Type

Location

HIV Advice & Information given?

Section 1: Substance use (Please use NA only if information is not disclosed or not answered).

Alcohol Average (units/day):

Week 4

Week 3

Week 2

Week 1

Opiates Average (g/day):

Week 4

Week 3

Week 2

Week 1

Crack Average (g/day)

Week 4

Week 3

Week 2

Week 1

Cocaine Average (g/day)

Week 4

Week 3

Week 2

Week 1

Amphetamines Average (g/day)

Week 4

Week 3

Week 2

Week 1

Cannabis Average (spliff/day)

Week 4

Week 3

Week 2

Week 1

Other Problem Substance Name

Section 2: Injecting risk behaviour (Please use NA only if information is not disclosed or not answered).

Injected

Week 4

Week 3

Week 2

Week 1

Inject with needle

Inject with needle or syringe used by someone else?

Inject using a spoon

Inject using a spoon, water or filter used by someone else?

Section 3: Crime (Please use NA only if information is not disclosed or not answered).

Shoplifting

Week 4

Week 3

Week 2

Week 1

Drug Selling

Week 4

Week 3

Week 2

Week 1

Theft Vehicle

Other Property Theft

Fraud etc

Committing assault or violence

Section 4: Health and social functioning (Please use NA only if information is not disclosed or not answered).

Psychological Health Status

Paid Work

Week 4

Week 3

Week 2

Week 1

Attended College or School

Week 4

Week 3

Week 2

Week 1

Physical Health Status

Acute Housing Problem

At Risk of Eviction

Quality of Life

Antidote TOP Form Submission

LONDON FRIEND MAIN OFFICE

86 Caledonian Road
London N19DN

020 7833 1674
office@londonfriend.org.uk

SOCIAL MEDIA LINKS

Charity number: 299307 - Company limited by guarantee (No. 1345530) - © All rights reserved - London Friend - 2024

Antidote TOP Form Submission

LONDON FRIEND MAIN OFFICE

86 Caledonian RoadLondon N19DN

020 7833 1674office@londonfriend.org.uk

SOCIAL MEDIA LINKS

Charity number: 299307 - Company limited by guarantee (No. 1345530) - © All rights reserved - London Friend - 2024

86 Caledonian Road
London N19DN

020 7833 1674
office@londonfriend.org.uk