ࡱ> '` ċbjbjDD *&&Pp? L L L $N@@@8xt\hb)2"828282n7v=D@$NhL +Cv6z6+C+C 8282>333+C" 882 R823+C33m| * " 82 1)@MC!)0T/e"T$ TL ^B0B"3BB_^B^B^BQe!^B^B^B+C+C+C+C\\\d@\\\@` $  RYAN WHITE PROGRAM PART A Charlotte Transitional Grant Area (TGA) Case Management Assessment Tool General: Agency ID #:  FORMTEXT      Date of Assessment:  FORMTEXT  _________     Client s full name:  FORMTEXT       Location of Assessment:  FORMTEXT       Was information obtained during the assessment provided by person(s) in addition to the client? Yes FORMCHECKBOX  No FORMCHECKBOX  If yes who?  FORMTEXT      Relationship:  FORMTEXT       Phone:  FORMTEXT      ******************************************************************************************** Please refer to original intake and assessment for any demographic information. ************************************************************************************ Education: Educational level: Grade School  FORMCHECKBOX  High School/GED FORMCHECKBOX  Associates Degree FORMCHECKBOX  Undergraduate Degree  FORMCHECKBOX  Graduate/Post Grad. Degree  FORMCHECKBOX  Reading Ability/Literacy: High  FORMCHECKBOX  Moderate  FORMCHECKBOX  Limited  FORMCHECKBOX  Race/Ethnicity: Race:  FORMCHECKBOX  African American/Black  FORMCHECKBOX  Latino/Hispanic  FORMCHECKBOX  Asian/Pacific Islander  FORMCHECKBOX  Native American  FORMCHECKBOX  Black/Non-Hispanic  FORMCHECKBOX  White/Non-Hispanic  FORMCHECKBOX  Other:  FORMTEXT       Housing: Apartment/Condo  FORMCHECKBOX  House  FORMCHECKBOX  Mobile Home  FORMCHECKBOX  Group Home  FORMCHECKBOX  Transitional  FORMCHECKBOX  Homeless  FORMCHECKBOX  Rent  FORMCHECKBOX  Own  FORMCHECKBOX  Other  FORMCHECKBOX  Also check one of the following: Permanent (stable)  FORMCHECKBOX  Non-Permanent  FORMCHECKBOX  Current Housing Programs: HOPWA  FORMCHECKBOX  Section 8  FORMCHECKBOX  Housing Authority  FORMCHECKBOX  None  FORMCHECKBOX  Unknown  FORMCHECKBOX  Other:  FORMTEXT       Does the client have any physical impairments/limitations that affect his/her safety in the home? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please describe FORMTEXT        Are there any structural or functional inadequacies in the client s home?Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please describe FORMTEXT       Adequate  FORMCHECKBOX  Overcrowded  FORMCHECKBOX  Criminal Activity  FORMCHECKBOX  No Indoor Plumbing  FORMCHECKBOX  Substandard  FORMCHECKBOX  Unaffordable  FORMCHECKBOX  Threat of Physical Violence  FORMCHECKBOX  Other: FORMTEXT       Unknown  FORMCHECKBOX   Make any other comments about the client s home environment you have observed that may have an effect on his/her ability to function independently FORMTEXT        Are there other persons (Adults/Non-dependent Children) in the household? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please note below: NameRelationshipAgeMay We Contact?Aware of HIV Status? FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX Does the client have dependent children? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, complete the following: NameDOBHIV StatusName of School/DaycareContact PersonPhone NumberAware of HIV Status? FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  Transportation: Does client have access to transportation? Yes  FORMCHECKBOX  No  FORMCHECKBOX If no, please describe client s ability to access transportation:  FORMTEXT       Insurance: Medicare: Yes  FORMCHECKBOX  No  FORMCHECKBOX  Medicare #:  FORMTEXT       Effective Date: FORMTEXT       A  FORMCHECKBOX  B  FORMCHECKBOX  D  FORMCHECKBOX  MEDICAID: Yes  FORMCHECKBOX  No  FORMCHECKBOX  MEDICAID #:  FORMTEXT       Effective Date: FORMTEXT       Expiration Date: FORMTEXT       Date applied if pending: FORMTEXT       VA Benefits: Yes  FORMCHECKBOX  No  FORMCHECKBOX  Effective Date: FORMTEXT       Expiration Date: FORMTEXT       Date applied if pending: FORMTEXT       ADAP: Yes  FORMCHECKBOX  No  FORMCHECKBOX  Effective Date: FORMTEXT       Expiration Date: FORMTEXT       Date applied if pending:  FORMTEXT       COBRA coverage: Yes  FORMCHECKBOX  No  FORMCHECKBOX  Name of Ins. Co.:  FORMTEXT      Group # FORMTEXT       Subscriber #: FORMTEXT      Effective Date: FORMTEXT      Expiration Date: FORMTEXT      Date applied if pending: FORMTEXT      Employer:  FORMTEXT       Private Insurance: Yes  FORMCHECKBOX  No  FORMCHECKBOX  Name of Ins. Co.:  FORMTEXT      Group # FORMTEXT       Subscriber #: FORMTEXT      Effective Date: FORMTEXT      Expiration Date: FORMTEXT      Date applied if pending: FORMTEXT      Employer:  FORMTEXT      Occupation:  FORMTEXT       Other coverage: Yes  FORMCHECKBOX  No  FORMCHECKBOX  Name of Ins. Co.:  FORMTEXT      Group # FORMTEXT       Subscriber #: FORMTEXT      Effective Date: FORMTEXT      Expiration Date: FORMTEXT      Date applied if pending: FORMTEXT      Employer:  FORMTEXT      Occupation:  FORMTEXT       Financial Resources: Household Income per month (includes income of client and other household members)  FORMTEXT       Income Expenses Client Income SourceStatus (please check one)AmountSourceAmountEmployment(yes FORMCHECKBOX  no FORMCHECKBOX  pending FORMCHECKBOX ) FORMTEXT      Rent/Mortgage FORMTEXT      SSD(yes FORMCHECKBOX  no FORMCHECKBOX  pending FORMCHECKBOX ) FORMTEXT      Car Payment FORMTEXT      SSI(yes FORMCHECKBOX  no FORMCHECKBOX  pending FORMCHECKBOX ) FORMTEXT      Transportation FORMTEXT      Food Stamps(yes FORMCHECKBOX  no FORMCHECKBOX  pending FORMCHECKBOX ) FORMTEXT      Credit Card/Loans FORMTEXT      TANF (yes FORMCHECKBOX  no FORMCHECKBOX  pending FORMCHECKBOX ) FORMTEXT      Health Care FORMTEXT      Unemployment(yes FORMCHECKBOX  no FORMCHECKBOX  pending FORMCHECKBOX ) FORMTEXT      Insurance FORMTEXT      VA Benefits(yes FORMCHECKBOX  no FORMCHECKBOX  pending FORMCHECKBOX ) FORMTEXT      Utilities FORMTEXT      Other(yes FORMCHECKBOX  no FORMCHECKBOX  pending FORMCHECKBOX ) FORMTEXT      Phone FORMTEXT      Total FORMTEXT      Food  FORMTEXT      Child Support FORMTEXT      AssetsAlimony FORMTEXT      SourceAmountEntertainment FORMTEXT      Life Insurance FORMTEXT       FORMTEXT      Other FORMTEXT      Checking FORMTEXT       FORMTEXT      Total Monthly Expenses FORMTEXT      Savings FORMTEXT       FORMTEXT      Total Monthly Income FORMTEXT      Property FORMTEXT       FORMTEXT      - Total Monthly Expenses FORMTEXT      Burial Insurance FORMTEXT       FORMTEXT      Total Monthly Cash Flow FORMTEXT      Total FORMTEXT       FORMTEXT      Confirmed Zero IncomeYes FORMCHECKBOX  No  FORMCHECKBOX  Legal Issues: Legal Documents Status: Please check as appropriate. DOCUMENTNEEDEDNOT INTERESTEDCOMPLETEDWill  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Durable Power of Attorney  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Living Will  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Health Care Power of Attorney  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Guardianship  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Burial Plans  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Other: FORMTEXT         FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Legal Problems Status: Please indicate information as appropriate. CHARGESAPPROXIMATE DATELOCATION (state, county)DISPOSITION FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       Health: Primary Care Physician: FORMTEXT      Phone Number:  FORMTEXT      Infectious Disease Physician:  FORMTEXT      Phone Number:  FORMTEXT      Medical Facility most often used:  FORMTEXT      Contact:  FORMTEXT      Phone Number:  FORMTEXT      Are there any known allergies (drugs, food, and animals, other)? Yes FORMCHECKBOX  No  FORMCHECKBOX  Please list known allergies  FORMTEXT       Does the client have any diagnosed health problems (heart disease, TB, hepatitis, other)? Yes FORMCHECKBOX  No  FORMCHECKBOX  Diagnosed Health ProblemsTreatmentsDate of Treatment FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Has the client ever been hospitalized? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please complete the following: DateHospitalLength of StayReason FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Dental: Does the client receive dental care? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes name of dentist:  FORMTEXT       Phone number:  FORMTEXT       Does the client have mouth/dental problems that affect what or how much she/he can eat: Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please describe:  FORMTEXT       Is there a history of opportunistic infections? Please check yes or no) HistoryDateOIYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      PCPYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      CMV RetinitisYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      HistoplasmosisYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      CryptosporidiumYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      Kaposis SarcomaYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      ShinglesYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      ToxoplasmosisYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      CoccidiomycosisYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      Crytococcal MeningitisYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      TBYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      Invasive Cervical CancerYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       Other? On PCP prophylaxis? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is there a history of other HIV related conditions? (Please check yes or no) FeversYes  FORMCHECKBOX  No  FORMCHECKBOX VirginitiesYes  FORMCHECKBOX  No  FORMCHECKBOX Night SweatsYes  FORMCHECKBOX  No  FORMCHECKBOX PIDYes  FORMCHECKBOX  No  FORMCHECKBOX ChillsYes  FORMCHECKBOX  No  FORMCHECKBOX ThrushYes  FORMCHECKBOX  No  FORMCHECKBOX FatigueYes  FORMCHECKBOX  No  FORMCHECKBOX Dysphagia Yes  FORMCHECKBOX  No  FORMCHECKBOX MalaiseYes  FORMCHECKBOX  No  FORMCHECKBOX Cold SoresYes  FORMCHECKBOX  No  FORMCHECKBOX Weight Loss >10 lbsYes  FORMCHECKBOX  No  FORMCHECKBOX SeizuresYes  FORMCHECKBOX  No  FORMCHECKBOX Loss of AppetiteYes  FORMCHECKBOX  No  FORMCHECKBOX Change in VisionYes  FORMCHECKBOX  No  FORMCHECKBOX Diarrhea > 1wkYes  FORMCHECKBOX  No  FORMCHECKBOX Periodontal DiseaseYes  FORMCHECKBOX  No  FORMCHECKBOX HerpesYes  FORMCHECKBOX  No  FORMCHECKBOX Short Term Memory LossYes  FORMCHECKBOX  No  FORMCHECKBOX SyphilisYes  FORMCHECKBOX  No  FORMCHECKBOX HepatitisYes  FORMCHECKBOX  No  FORMCHECKBOX  If yes: please comment on these illnesses or others:  FORMTEXT        Describe any other health concerns not identified above:  FORMTEXT        Does the client have any visual or hearing impairment?  FORMTEXT        What affect does the client feel his/her health status has on their ability to work?  FORMTEXT        What does the client identify as the greatest barriers to keeping medical appointments?  FORMTEXT        How frequently does the client miss or reschedule medical appointments?  FORMTEXT        **Current Medications: Please complete the Medical Review and Medications List as part of this assessment/reassessment. Include HIV, Non-HIV, Psychotropic Medications, OTC Medications, Herbal Remedies, etc, on the list. Include the most current CD 4 and Viral Load data available. If taking medications how does the client feel after taking medications?  FORMTEXT        Name of pharmacy/service and contact number (if applicable):  FORMTEXT        What barriers does the client identify to taking medications as prescribed?  FORMTEXT        Identify any past and/or current self-treatments, alternative therapies, etc., and its importance to the client. FORMTEXT        How does the client rate his/her overall health?  FORMCHECKBOX  excellent  FORMCHECKBOX  good  FORMCHECKBOX  fair  FORMCHECKBOX  poor How many meals does the client eat each day?  FORMCHECKBOX  0-1  FORMCHECKBOX  2-3  FORMCHECKBOX  4-5  FORMCHECKBOX  6+ Does the client seem to have a well balanced diet (fruits, vegetables, grains, proteins and dairy)? 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hUhTX hTX>* hAhTXhAhTX>*#jhAhTX>*UmHnHujhAhTX>*Uj,hTXhs>*U(~uuudvfvvvoAkd$$Ifl&r& t644 laytA $Ifgd.Lgd /uAkd$$Ifl&r& t644 laytAvvvwwxxyy((((((((( ("(<(gd /u$a$gd /ugd /uAkd$$Ifl&r& t644 laytAx%x&x'x9x:xHxIxJxVxWxexfxgxpxqxxxxxxxxxxxyy y yyyyymynyxyyyz(vtUj hTXhs>*Uh(yhTX>*jh(yhTX>*U hTX5j hsUj hsUjhAhTXU hAhTXj$ hsUj hsUj8 hsUjhTXUj hsUhTX'      ADL s/IADLs: Describe client s ability to function independently in the following areas. Activity of Daily LivingDoes Client Need Assistance?Type of Assistance NeededSource of AssistanceAbility to AmbulateYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT        FORMTEXT      Ability to Transfer Self Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT        FORMTEXT      Ability to Feed SelfYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT        FORMTEXT      Ability to Toilet Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT        FORMTEXT      Ability to Bathe SelfYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT        FORMTEXT      Ability to Groom SelfYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT        FORMTEXT      Ability to Dress SelfYes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT        FORMTEXT       Others? FORMTEXT       Instrumental Activity of Daily Living Does the Client Need Assistance? Type of assistance needed: Source of assistance received: Housecleaning Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT        FORMTEXT       Laundry Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT        FORMTEXT       Shopping Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT        FORMTEXT       Medication Management Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT        FORMTEXT       Money Management Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT        FORMTEXT       Ability to use phone Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT        FORMTEXT       Others?  FORMTEXT        Recreation/Leisure: What does the Client do for fun or stress relief?  FORMTEXT        Spirituality: How does Religion play a role in the Client s life? FORMTEXT        What gives the client s life purpose or meaning? What gives the client hope?  FORMTEXT        Are there any rituals or beliefs that may impact your healthcare? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please describe:  FORMTEXT        Substance Use: Identify current or past use of any substances including alcohol, tobacco, prescription and OTC medications: SubstanceFrequency of use over past 30 daysAverage quantity of use/dayDate of last useDoes client identify use as a problem FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is the client willing to receive a referral to a substance use counselor? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If no explain: FORMTEXT        Risk:  FORMCHECKBOX  Substance Abuse  FORMCHECKBOX  Mental Illness  FORMCHECKBOX  Bisexual Contact  FORMCHECKBOX  Heterosexual Contact  FORMCHECKBOX  Blood Product Recipient  FORMCHECKBOX  Sexual partner of prisoner FORMCHECKBOX  Exposed in healthcare Setting  FORMCHECKBOX  Homosexual contact  FORMCHECKBOX  Perinatal Transmission  FORMCHECKBOX  Other/undeterminedRisk Reduction Counseling Received  FORMCHECKBOX Yes  FORMCHECKBOX No  FORMTEXT        What is the client s understanding and use of safer practices to avoid transmission of or re-infection with HIV?  FORMTEXT        What are the barriers to the client using safer practices? FORMTEXT        Does the client believe s/he may currently have a STD?  FORMTEXT       Does the client need referral for STD testing and/or treatment? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Does the client need safer sex and/or drug use education? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Has client notified past/current partners of HIV status? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If no, describe what steps you took to assist client in this process (such as referral to DIS/Health Department).  FORMTEXT        Please make any other comments you feel may impact client s efforts at risk reduction:  FORMTEXT        Describe your sleep pattern. (Do you wake up in the middle of the night? Do you wake up early? Do you have trouble falling asleep?). Is this a  regular pattern for you? Do you feel rested upon waking? FORMTEXT       Mental Health: Is client s grooming/appearance appropriate? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is client oriented x3? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Motor coordination:  FORMCHECKBOX  good  FORMCHECKBOX  fair  FORMCHECKBOX  poor Thought content:  FORMCHECKBOX  Clear  FORMCHECKBOX  Impaired If impaired describe FORMTEXT       Memory:  FORMCHECKBOX  Impaired  FORMCHECKBOX  Unimpaired If impaired describe FORMTEXT       Judgment:  FORMCHECKBOX  Impaired  FORMCHECKBOX  Unimpaired Insight:  FORMCHECKBOX  Impaired  FORMCHECKBOX  Somewhat Impaired  FORMCHECKBOX  Intact. Appears to be under the influence of a substance? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Do you have any psychiatric history/diagnosis? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, explain  FORMTEXT       Have you had a significant period (that was not a direct result of drug/alcohol use) in which you have? FORMTEXT       Past 30 daysLifetime CommentsExperienced serious depression  FORMTEXT       FORMTEXT       FORMTEXT       Experienced serious anxiety or tension FORMTEXT       FORMTEXT       FORMTEXT      Experienced hallucinations  FORMTEXT       FORMTEXT       FORMTEXT      Experienced trouble understanding, concentrating or remembering  FORMTEXT       FORMTEXT       FORMTEXT      Experienced trouble controlling anger that led to physical violence FORMTEXT       FORMTEXT       FORMTEXT      Experienced serious thoughts of suicide FORMTEXT       FORMTEXT       FORMTEXT      Attempted suicide FORMTEXT       FORMTEXT       FORMTEXT      Been prescribed medication for any psychological/emotional problem FORMTEXT       FORMTEXT       FORMTEXT      Wanted to hurt or harm yourself (including self-mutilation) FORMTEXT       FORMTEXT       FORMTEXT      Seriously wanted to hurt or harm someone else  FORMTEXT       FORMTEXT       FORMTEXT       Are there any life crises affecting you now? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Please describe FORMTEXT       Would you like to talk to someone about your feelings? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Are you interested in counseling/therapy/support group? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Have you ever received mental health or counseling services? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, name of provider FORMTEXT       Diagnosis?  FORMTEXT       Are you currently receiving mental health? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, name of provider FORMTEXT       Diagnosis?  FORMTEXT       Have you ever been hospitalized for mental health? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please provide: DateWhere HospitalizedReasonDuration FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Are you taking medications for mental illness now or have you taken any medication in the past? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Domestic Violence: Have you ever been a victim of domestic violence (verbal, mental or physical) Yes  FORMCHECKBOX  No  FORMCHECKBOX  Are you currently involved in an abusive relationship? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Community Resources and Support: Does client s have knowledge/understanding of available community resources? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is the client currently receiving services? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please list below: AgencyContact NameContact NumberServices Received FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       Client s primary source of emotional social support: Name: FORMTEXT       Address: FORMTEXT      Phone: FORMTEXT       Comments:  FORMTEXT       ServiceNeedsReceivesServiceNeedsReceivesAIDS Clinical Trials FORMCHECKBOX  FORMCHECKBOX Advanced Directives FORMCHECKBOX  FORMCHECKBOX Budget Counseling FORMCHECKBOX  FORMCHECKBOX Burial Assistance FORMCHECKBOX  FORMCHECKBOX Case Management FORMCHECKBOX  FORMCHECKBOX Care Teams FORMCHECKBOX  FORMCHECKBOX Clothing FORMCHECKBOX  FORMCHECKBOX Dental Care FORMCHECKBOX  FORMCHECKBOX Continuing education FORMCHECKBOX  FORMCHECKBOX Drug/Alcohol Treatment FORMCHECKBOX  FORMCHECKBOX Domestic Violence FORMCHECKBOX  FORMCHECKBOX Food Assistance FORMCHECKBOX  FORMCHECKBOX Emergency Shelter FORMCHECKBOX  FORMCHECKBOX Food Stamps FORMCHECKBOX  FORMCHECKBOX Employment FORMCHECKBOX  FORMCHECKBOX Legal Assistance FORMCHECKBOX  FORMCHECKBOX HIV Education FORMCHECKBOX  FORMCHECKBOX Medical- HIV Specialty Care FORMCHECKBOX  FORMCHECKBOX Home delivered Meals FORMCHECKBOX  FORMCHECKBOX Nutritional Counseling FORMCHECKBOX  FORMCHECKBOX Hospice Services FORMCHECKBOX  FORMCHECKBOX Pharmacy Assistance FORMCHECKBOX  FORMCHECKBOX Information and Referral FORMCHECKBOX  FORMCHECKBOX Post Test Counseling FORMCHECKBOX  FORMCHECKBOX Mental Health- Outpatient FORMCHECKBOX  FORMCHECKBOX Risk Reduction Counseling FORMCHECKBOX  FORMCHECKBOX Nutrition Supplements FORMCHECKBOX  FORMCHECKBOX Spiritual Support FORMCHECKBOX  FORMCHECKBOX Medicaid FORMCHECKBOX  FORMCHECKBOX SSI/SSDI FORMCHECKBOX  FORMCHECKBOX Medical-Primary Care FORMCHECKBOX  FORMCHECKBOX Support Groups FORMCHECKBOX  FORMCHECKBOX Medicare FORMCHECKBOX  FORMCHECKBOX Treatment Adherence FORMCHECKBOX  FORMCHECKBOX Partner Notification FORMCHECKBOX  FORMCHECKBOX  Referrals to be made:  FORMTEXT        Summary: Summarize information gathered from Assessment in a concise coherent manner. Essentially you are identifying problems and concerns that became evident during your assessment. Please also include strengths, weaknesses that you have identified in the client.  FORMTEXT        I, ______________________________, certify that all the information I have given is true and accurate to the best of my knowledge and belief. I agree to provide financial and other verification that may be needed to receive services. Client (guardian) Signature_____________________________________________Date:_____________________ *Witness Signature (if needed):_________________________________________ Date: ______________________ Case Manager Signature_______________________________________________Date:_____________________ *If you do not have a third party witness available, to witness marks, please write a note of explanation and get your supervisor to initial and date this form.        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