CDC HIV-STC Intake Assessment Form

Intake Assessment FormClient Name:Client Record #:Intake Date:Complete this form from the client interview and chart review at intake. Sections surrounded by a double border arerequired. No changes should be made to the Intake Assessment Form. Significant client changes should be recordedon the Reassessment Form.1. Clinical InformationChart Review or Client InterviewDate of First Known Visit to This Agency for Any Service:HIV Status: (check only one)HIV , Not AIDSHIV , AIDS status unknownCDC-Defined AIDSHIV Diagnosis Date:If AIDS, AIDS Diagnosis Date:HIV Risk Factor: (check all that apply)MSMHemophilia/coagulation disorderIDUPerinatalHeterosexualRisk factor not reported or not identifiedBlood transfusion/componentsDo you currently have a primary care physician (PCP)/HIV primary care provider?YesNoLast PCP Visit Prior to Enrollment:orUnknownN/AInitial/Referral Visit with PCP within This Program:Most Recent CD4 Counts and Viral Load Measures from On or Before the Program EnrollmentDate: (Start with the most recent)CD4 RecordsCD4 countSTEPS to Care Intake Assessment FormIf none are available, check box at right:CD4 % (optional)No CD4 count on recordDatePage 1 of 9

Client Name:Client Record #:Viral Load RecordsIf none are available, check box at right:Viral Load CountNo viral load count on recordViral Load es client have any other medical conditions requiring treatment?DateYesNoUnknownYesNoUnknownIf Yes, what condition(s)? (Check all that apply)CancerKidney diseaseDiabetesHepatitis CHeart disease/hypertensionTuberculosis (TB)Liver diseaseAsthmaOther (Specify: )Has client ever received a mental health diagnosis?If Yes, what diagnosis or diagnoses? (Check all that apply)DepressionBipolar disorderAnxiety disorder (panic, GAD, etc.)Psychosis (schizophrenia, etc.)PTSDHIV-associated dementiaOther (Specify: )2. Antiretroviral Treatment (ART) ReviewIs client currently prescribed ART?Chart Review or Client InterviewYesNoIf client is not on ART, why is the client not currently prescribed ART? (check only one)Not medically indicatedNot ready—by PCP determinationIntolerance/side effects/toxicityPayments/insurance/cost issueClient refusedOther reasonUnknownSTEPS to Care Intake Assessment FormPage 2 of 9

Client Name:Client Record #:3. Client InformationClient InterviewTotal Number in Household: (including the client)Current Employment Status: (check only one)Full-timePart-timeUnemployedUnpaid volunteer/peer workerOut of workforceOther (Specify: )DeclinedHighest Level of Education Achieved: (check only one)No schooling8th grade or lessBachelors/technical degreeHigh school/GED or equivalentSome collegeDeclinedPostgraduateSome high schoolPrimary Language Spoken (i.e., at home): (check only one)EnglishSpanishOther (Specify: )DeclinedIf Primary Language Is Not English: Secondary Language Spoken: (check only one)EnglishSpanishOther (Specify: )DeclinedCountry of Birth: (check only one)USAUS territory/dependencyOther country (Specify: )Puerto RicoOther (Specify: )DeclinedIf not USA, ask: In what month and year did you first come to the USA? (mm/yyyy)Declined4. Insurance InformationChart Review or Client InterviewInsurance Status:UninsuredInsured(If Insured, complete insurance details below.Otherwise, skip to Section 5: Financial Information)STEPS to Care Intake Assessment FormPage 3 of 9

Client Name:Client Record #:Check all that apply, and complete the related details/dates on each checked insurance type:Insurance TypePrivateADAP/ADAP Medicaid or CHIPInsurance details(check only one)Effective DateEnd/Expiration DateEmployer planUnknownIndividual planN/A(check all that apply)ADAP (Rx Coverage)UnknownADAP PlusN/A(check only one plan type)SNP (special needs plan)MCO (managed careorganization)FFS (fee-for-service)UnknownNot sure which typeN/AMedicareUnknownN/AMilitary, VA, TricareUnknownN/AIHS (Indian Health Service)UnknownN/AOther Public InsuranceUnknownN/A5. Financial InformationClient InterviewWhat is your annual household income? per yearSTEPS to Care Intake Assessment FormPage 4 of 9

Client Name:Client Record #:We will be asking you questions in the next section about substance use. Some of these questions may seempersonal in nature, but we ask them of everyone in this program.» Please answer honestly. You may refuse to answer a question; refusing will not affect your care.» Please feel free to ask if you need any of the questions explained to you.» If you do not want to answer a question now, please tell me and we will return to it another time.6. Use of Prescriptions, Injectables, and Other SubstancesClient InterviewHave you used any of the following substances? Read the list starting with tobacco.Substance have youever usedthis?AlcoholMarijuanaPCP/HallucinogensFor use in past 3 months,ask: How often do youuse?For use in past 3 months, ask:How have you taken this?(check all that apply)* If haven’t used any substance EVER, skip to Section 7.Haven’t used anyTobaccoIf ever used it,ask: In the past 3months?YesYescigarettes smokedweekly (for otherforms of tobacco, #times used weekly) orOrally (chewing tobacco)SmokedNoNo weeklyInhaled/snorted (snuff)DeclinedDeclinedDeclined(reminder: 1 pack 20 cigarettes)Declined (no answer)YesYesdrinks weekly orNoNo weeklyDeclinedDeclinedDeclinedYesYestimes weekly orOrally (eaten/swallowed)NoNo weeklySmokedDeclinedDeclinedDeclinedDeclined (no answer)YesYestimes weekly orOrally (eaten/swallowed)NoNo dInjectedDeclined (no answer)Crystal MethYesYestimes weekly orOrally (eaten/swallowed)NoNo dInjectedDeclined (no answer)STEPS to Care Intake Assessment FormPage 5 of 9

Client Name:Client Record #:Cocaine/CrackYesYestimes weekly orOrally (eaten/swallowed)NoNo dInjectedDeclined (no answer)HeroinYesYestimes weekly orOrally (eaten/swallowed)NoNo dInjectedDeclined (no answer)Rx Pills to GetHighYesYestimes weekly orOrally (eaten/swallowed)NoNo dInjectedDeclined (no answer)Hormones/SteroidsYesYestimes weekly orOrally (eaten/swallowed)NoNo d (no answer)Anything Else:YesYestimes weekly orOrally (eaten/swallowed)NoNo dInjectedDeclined (no answer)If client has, at this interview, reported injecting any substance listed in the table above, select “Yes” to the question belowand select “in the past 3 months” beneath that. Ask the client directly about sharing injection equipment.Have you ever injected any drug or substance? If No, go to Section 7.YesNoDeclinedIf Yes, when was the last time you injected any substance?In the past 3 monthsBetween 3 and 12 months agoMore than 12 months agoDeclinedSTEPS to Care Intake Assessment FormPage 6 of 9

Client Name:Client Record #:If the client reported any injection behavior in the past 3 months, ask:Do you currently receive clean syringes from a syringe exchange program or pharmacy?YesNoDeclinedHave you ever shared needles or injection equipment with others?YesNoDeclinedIf Yes, when was the last time you shared needles or injection equipment?In the past 3 monthsBetween 3 and 12 months agoMore than 12 months agoDeclined7. Living Arrangement/Housing InformationClient InterviewAre you currently enrolled in a housing assistance program?YesNoDeclinedIf Yes, agency:UnknownWhat is your current living situation? (check only one box at left)Homeless/Place not meant for human habitation (such as a vehicle, abandoned building, or outside)Emergency shelter (non-SRO hotel)Single room occupancy (SRO) hotelOther hotel or motel (paid for without emergency shelter voucher or rental subsidy)Supportive housing program If checked, complete the indented detail questions below:Transitional congregateTransitional scattered-sitePermanent congregateHIV housing program?YesNoPermanent scattered-siteRoom, apartment, or house that you rent (not affiliated with a supportive housing program)Staying or living in someone else’s (family’s or friend’s) room, apartment, or houseHospital, institution, long-term care facility, or substance abuse treatment/detox centerJail, prison, or juvenile detention facilityFoster care home or foster care group homeApartment or house that you ownSTEPS to Care Intake Assessment FormPage 7 of 9

Client Name:Client Record #:Since what date have you been living in yourcurrent situation?(mm/yyyy)Or select one of the following:UnknownDeclinedHow long do you expect to be in your currentliving situation? If you do not know, what isyour best guess? (check only one)At least 1 year1 month— 6 months6 months— 12 months 1 monthWere you ever homeless?YesNoDeclinedIf Yes, when were you last homeless?(mm/yyyy)Do not ask if client is homeless:What are your current housing issues? (check all that apply)N/ACostSpace/configuration (e.g. too small)Doubled-up in the unitConflict with others in householdHealth or safety concernsRelease from institutional settingEviction or pending evictionOther (Specify: )Expanding household (e.g. newborn)8. Legal and Incarceration HistoryHave you ever served any time in jail, prison, or juvenile detention (JD)?If Yes, have you served any time in the past 12 months?Are you currently on parole/probation?STEPS to Care Intake Assessment FormClient ge 8 of 9

Client Name:Client Record #:Notes:Staff Member Completing Form:NameSTEPS to Care Intake Assessment FormDate:SignaturePage 9 of 9

Intake Assessment Form Client Name: _ Client Record #: _ Intake Date: _ Complete this form from the client interview and chart review at intake. Sections surrounded by a double border are required. No changes should be made to the Intake Assessment Form. Significant client changes should be recorded on the Reassessment F orm. 1.