ࡱ>  Èbjbj 4ee |xx8dxt+*******$m-0* +9" +xxE+MMM0xx8*M*MMR')s3@~(*[+0+(fI2]I2<)I2)""M:N + +A +I2 >:  PACT is a program designed to assist people with AIDS, address barriers to ART adherence, and improve utilization of medical and social resources. Date of Referral___________________ Eligibility Information and Necessary Documentation: Please check as appropriateYNCriteria((Location Resident of Dorchester, Roxbury, Mattapan, Jamaica Plain, Roslindale, Hyde Park, South End, Chelsea, Revere, Everett, East Boston, Charlestown, Cambridge, Allston, Somerville, and parts of Malden and Medford. Other neighborhoods will be considered based on proximity to enrolled PACT clients.((CD4  CD4 count d"500 cell/l or CD4 Percent d"18% (w/in the last 6 months)((HIV Viral Load - e"1000 copies/mL on at least two blood draws in the past year, including the latest blood draw within the last three months((ART First prescription of ART at least 6 months before referral or not-prescribed due to MD assessment of non-adherence any time in past year((History of non-adherence to ART(Current medication list: Please attach current medicine list(Lab work attachment: Please attach copies of CD4, HIV viral load, and resistance genotyping done in the past 12 months. If lab results do not exist for the three months prior to referral, please repeat the tests for baseline purposes. PACT is a program designed to assist people with AIDS, address barriers to ART adherence, and improve utilization of medical and social resources. 1Patient Information2Referrer InformationName: Email: Clinic/Hospital/Location: Relationship to Client:Address: Referrer Name & Specialty: Phone: Email:Phone: Alternative Phone:How did you hear about PACT? _______________________________ Date of Referral _____________ 3Description of History of Medication Adherence and Possible Barriers:  4Common concerns/behaviors that many patients experience: Explain all that apply.Psychiatric Diagnosis Mental Health Symptoms Cognitive Deficits Substance Use Domestic Violence Housing Instability Social Isolation AIDS Defining Illness and AIDS Diagnosis Year  5((( Other Factors that may influence eligibility: Explain all that apply (((Risk of death in the next 6 months Significant ART resistance (2 of 3 classes) Major co-morbidities (end stage liver, heart, renal disease or PML, dementia) 6Demographics:DOB: ___/___/_____ SSN: _____-_____-_____ Country of Birth:Race: (White (Black/African American (American Indian (Other: (Asian (Pacific Islander (More than one race Latino : (Yes (No Gender: (Male (Female (Transgender (( Male to Female ( Female to Male) (Other:Language: (Eng. (Span. (Port. (H. Creole (Other :Insurance: Policy #: 7General Information:Emergency Contact: Emergency Contact Phone: Disclosed to this person: Y / N HIV MD Name & Contact Information: Email:PCP Name & Contact Information: Email: 8Other information:Other social issues relevant to health status and referral reason: What is clients support system? Are there HIV disclosure issues?  PACT OFFICE USE ONLY(Eligible (Not Eligible (ExceptionException Reason:SignatureDate       PAGE \* MERGEFORMAT 1 PLEASE FAX/EMAIL TO: Rachel Weidenfeld at (857  ! 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