My Shared Life – User Details for England (V3 June 2017)

This form only needs to be completed once, prior to the completion of a baseline questionnaire for the Shared Lives user. Those questions marked with an * are mandatory.

* Enter a Pseudonym for the Shared Lives user or their First Name, Surname and Date of Birth
Pseudonym
First Name
Surname
Date of Birth
* At birth, what sex was the Shared Lives user described as?
Please tick () one box
Male /
Female /
Intersex /
Prefer not to say /
* How does the Shared Lives user think of themselves now?
Please tick () one box
Male /
Female /
In another way /
If “In another way” please specify below:
Which of these client groups does the Shared Lives user belong to?
Please tick () all boxes that apply
Learning Disability /
Mental Health /
Support needs associated with old age except dementia /
Dementia /
Physical Impairment /
Transition - Disabled Children /
Drugs or Alcohol /
Transition - Non-Disabled Care Leaver /
Intermediate Care / Reablement /
Parent with Child /
Offenders /
Other /
If “Other” please specify below:
* Which local authority is responsible for the Shared Livers user
What is the Shared Lives user’s nationality?
Please tick () one box
British /
English /
Irish /
Northern Irish /
Other /
Scottish /
Welsh /
Prefer Not to Say /
Not Asked /
Unknown /
If “Other” please specify the Shared Lives user’s nationality below:
What is the Shared Lives user’s ethnicity?
Please tick () one box
English / Welsh / Scottish / Northern Irish / British /
Irish /
Gypsy or Irish Traveller /
Northern Irish /
Any other White background /
White and Black Caribbean /
White and Black African /
White and Asian /
Any other Mixed / Multiple ethnic background /
Indian /
Pakistani /
Bangladeshi /
Chinese /
Any other Asian background /
African /
Caribbean /
Any other Black / African / Caribbean background /
Arab /
Any other ethnic group /
Prefer Not to Say /
Not Asked /
Unknown /
If “Other” please specify the Shared Lives user’s ethnicity below:
What is the Shared Lives user’s religion?
Please tick () one box
No Religion /
Christian (all denominations) /
Buddhist /
Hindu /
Jewish /
Muslim /
Any other religion /
Prefer Not to Say /
Not Asked /
Unknown /
If “Any other religion” please specify the Shared Lives user’s religion below:
What is the Shared Lives user’s sexual orientation
Please tick () one box
Heterosexual or Straight /
Gay Man /
Lesbian / Gay Woman /
Bisexual /
Other /
Don’t Know /
Prefer Not to Say /
Not Asked /
Unknown /
If “Other” please specify the Shared Lives user’s sexual orientation in the space below:

1