Chemsex Triage Form
Contact information
Please provide your name, address and an email address so the team can contact you back. Please note this service is only for people aged 18 and over and living in Greater Manchester.
Name
First Name
Last Name
Birthdate
-
Day
-
Month
Year
Date
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Triage Questions
Please answer these 5 short questions so we can identify what the best support for you.
Is this situation causing you unwanted issues? 1-10 (10 being that they are causing major unwanted issues).
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Number - situation causing you unwanted issues
How out of control of this situation do you feel just now? 1-10 (with 10 being completely out of control).
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Number - How out of control of this situation do you feel
If you could, would you want to change this situation? 1-10 (with 10 being I completely want to change this situation).
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Number - would you want to change this situation
What is ‘this situation’ for you? Please provide a short explanation in your own words.
Would you like to speak to someone about changing your situation?
Yes
No
Total Score (For Internal Use)
Submit
Should be Empty: