**Sample Initial Assessment Template**

**Note: If a Screening or Eligibility Form was completed on the client,
sociodemographic and HIV**

**testing data can be copied from those forms to this one.**

**^®G200^Date of Assessment**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®H09^Worker ID**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®G102^Client ID**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Name** First
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Middle
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Last
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**City**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®G120^State**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®H18^Recruitment Source** (Type of service the agency was providing
when client was referred to intervention)

Counseling and Testing Health Communication / Public Information

PCRS CRCS

Outreach Intake / Screening

Health Education / Risk Reduction Other
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Don't know

**^®H13^Recruitment Source** (How client learned about the intervention,
if no outreach or referrals?)

Agency Advertisement Self Partner

Family / friend Don't know Other
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SAMPLE INITIAL ASSESSMENT TEMPLATE**

**I. Psychosocial Assessment** Page

Demographics
**..........................................................................................**
3

HIV status and testing history
**......................................................................**
4

Basic needs
**.............................................................................................**
4

Independent living
**....................................................................................**
5

Living arrangement
**...................................................................................**
5-6

Transportation
**.........................................................................................**
6

Legal issues
**...........................................................................................**
6

Social support
**..........................................................................................**
7

**II. Risk Assessment**

General HIV transmission risk factors
**............................................................** 8

Substance use
**.........................................................................................**
9-10

Sexual risk
**.............................................................................................**
11-13

**III. Mental Health Assessment
.................................................................................**
14-15

**IV. Medical Assessment**

All clients
**.................................................................................................**
16

HIV-positive clients only
**..............................................................................**
17-18

**V. Summary of Initial Session, Potential Needs & Current Services ...
...........................** 19-20

**VI. Referrals and Bridge to Prevention Plan
................................................................** 21

**I. PSYCHOSOCIAL ASSESSMENT**

**[DEMOGRAPHICS]{.underline}**

**^®G124^Current Gender** Male Female Transgender  MTF OR FTM

**^®G123^Gender at Birth** Male Female

**^®G116^ Race** (Check all that apply) **^®G114^Ethnicity ^®G115^ If
Hispanic/Latino,**

American Indian/Alaskan Native Hispanic/Latino **what nationality?**

Asian Non-Hispanic \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Black or African-American Refused to answer

Native Hawaiian/Pacific Islander Don't know

White

Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Refused to answer

Don't know

**^®\ G112^DOB \_\_\_\_/\_\_\_\_/\_\_\_\_\_\_\_\_\_
^®G113^Age\_\_\_\_\_\_**

**^®G121^Does the client speak English?** No Yes **^®G122^If no, what
language? \_\_\_\_\_\_\_\_\_\_\_\_\_**

**Sexual Orientation ^\*G126^Relationship Status**

Straight/Heterosexual Single / Never Married

Bisexual Married or partnered

Lesbian/Homosexual/Gay Married but separated

Refused to answer Divorced

Don't know Widowed

Other \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Refused to answer

**^®\ G127^Highest Grade Completed**

> No schooling completed
>
> 8^th^ Grade or less
>
> Some high school
>
> Finished HS / GED
>
> Some college
>
> Bachelor's degree
>
> Post graduate degree
>
> Refused to answer
>
> Don't know

**[HIV STATUS AND TESTING HISTORY]{.underline}**

**^®\ G204^HIV test ^®\ G205^Result of ^®\ G206^If negative, year
^®\ G207^If positive, year of**

**before today? prior test of most recent test first positive test**

No (Refer to testing) Positive \_\_\_\_/\_\_\_\_/\_\_\_\_\_\_
\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_\_

Yes Negative Don't know Don't know

Refused to answer Refused to answer

Don't know (Refer) Don't know (Refer)

**^®G301^If positive, what does HIV testing documentation show:**

Positive/reactive NAT-positive Negative Indeterminate

Invalid No result

**^®\ G302^What is the date of the confirmatory HIV test?**
\_\_\_\_\_/\_\_\_\_/\_\_\_\_\_\_\_\_

**^®\ G303^If positive, where is the source of information coming from
indicating client is positive?** Within agency Provided by another
agency Provided by client

**^®\ G304^What is the date your agency received the confirmed HIV test
result?** \_\_\_\_/\_\_\_\_/\_\_\_\_\_

## [BASIC NEEDS]{.underline}

**Employment If working, level of satisfaction**

Full time Not at all **Does the client require**

Part time Slightly **foodbank assistance?**

Disabled Moderately No Yes

Unemployed, Considerably

looking for work Extremely **Does the client require**

Unemployed, not **clothing assistance?**

looking for work No Yes

**Annual income from employment** \$ \_\_\_\_\_\_\_\_\_\_\_\_\_
**Primary source** \_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Other sources of income** \$
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Source**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SUMMMARY: BASIC NEEDS ASSESSMENT (Choose one)**

> Client is lacking resources to provide for basic needs (food,
> clothes). Immediate intervention is
>
> needed.
>
> Client has some resources to provide for basic needs; however these
> resources are inadequate. There is need for intervention, but the need
> is not critical.
>
> Client has adequate resources to provide for needs. There is no need
> for intervention.

**[INDEPENDENT LIVING]{.underline}**

**Does the client have difficulties with self-care and personal hygiene
activities, such as bathing or showering, getting dressed, fixing hair,
brushing teeth, going to the bathroom, preparing meals or cleaning
dishes?** No Yes

If yes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[LIVING ARRANGEMENTS]{.underline}**

**Has the client had stable housing in the past 90 days?** No Yes

**^®\ G203^What type of living arrangement has the client had in the
past 90 days?**

Permanent housing (apartment, home, foster care---There is no time limit
on staying privileges)

Non-permanent housing (Includes homelessness as well as transient and
transitional housing)

Institution (Establishment provides living quarters and care for
elderly, chronically ill, or handicap)

Refused to answer

Don't Know

Other (specify)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**How satisfied is client with living arrangement?**

Not at all

Slightly

Moderately

Considerably

Extremely

**How many people live in client's household?** \_\_\_\_\_\_\_\_\_

**Total number of children/dependents needing care from client**
\_\_\_\_\_\_\_\_\_

**Who is responsible for care of children/dependents if client is not**
**available?** \_\_\_\_\_\_\_\_\_

Describe people living in client's household

Name Age Relationship HIV Status Live in household

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
No Yes

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
No Yes

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
No Yes

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
No Yes

**Does client want to change his or her living situation?** No Yes

If yes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Are there any other housing issues related to the health and safety of
the client?** No Yes

If yes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Contact information**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name Relation Telephone number (if different)

**Is it okay to contact this person in case of an emergency?** No Yes
**Is it okay to use the agency's name when speaking with this person?**
No Yes

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name Relation Telephone number (if different)

**Is it okay to contact this person in case of an emergency?** No Yes

**Is it okay to use the agency's name when speaking with this person?**
No Yes

**[TRANSPORTATION]{.underline}**

**Does client have own transportation?** No Yes

**Does client have access to and funds for public transportation?** No
Yes

**Does client need specially arranged transportation?** No Yes

**Does client need other transportation arrangements?** No Yes

If yes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[LEGAL NEEDS]{.underline}**

**Is the client on probation or parole?** No Yes

**Are there other legal issues?** No Yes

If yes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[SOCIAL SUPPORT]{.underline}**

**Evaluate the strength of the client's social support system by placing
a check or place the appropriate response in the box below:**

  ------------------ -------------- ------------- ---------- -------------------
                     Can talk to    Can borrow    Person     Level of support?
                     this person    money if      knows      1= Significant
                     about          needed from   client's   support 2 =
                     anything?      this person?  HIV        Occasional support
                                                  status?    3 = Weak/No support
                                                             NA = Not applicable

  Spouse                                                      

  Partner                                                     

  Parent                                                      

  Child                                                       

  Sibling/relative                                            

  Friends                                                     

  Support group                                               

  Guardian                                                    

  Church                                                      

  CBO staff                                                   

  Other (specify)                                             
  ------------------ -------------- ------------- ---------- -------------------

**Describe the client's spouse/partner relationship. A 'spouse/partner'
is someone with whom the client feel attached to emotionally.**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Overall level of satisfaction with support ("How satisfied are you
with your level of social support?")**

Not at all Slightly Moderately Considerably Extremely

**SUMMARY: SOCIAL SUPPORT ASSESSMENT (Choose one)**

> Client appears to be isolated and lacking in any significant, reliable
> source of social support.
>
> Client feels the need for support. Immediate intervention is needed.
>
> Client appears to be lacking in any significant sources of social
> support, but seems comfortable with the situation. Intervention may be
> explored at a later time.
>
> Client has support but feels the need for more resources. This may be
> explored more fully.
>
> Client has an active, acceptable social support network. There is no
> need for intervention.

**II. RISK ASSESSMENT**

To make the interview flow more naturally, you may not have to ask
client questions for which you already know answers, but be sure to
record the information.

**[GENERAL HIV TRANSMISSION RISK FACTORS]{.underline}**

**^®\ I01^What recall periods will you be using to ask the client the
following questions?** (Check one)

\[NOTE: As of January 2006, PEMS requires asking about 15 OR 30 day
recall for risk behavior PLUS asking about 90 day recall for the Initial
Assessment. PEMS items for 15 OR 30 day recall are contained in Appendix
D-2. This form provides 90-day recall items, which is the recommended
recall period for CRCS. Agencies may choose another recall period
instead of 90 days by checking the box below\].

> **** 90 days
>
> **** Local period (specify
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)

**^®\ I02,\ ®G211^What risk factors did the client engage in within 90
days that placed the client at potential risk for HIV exposure and/or
transmission?** (Check all that apply.)

> Injection drug use (Illicit use of injection drugs/substances,
> including narcotics, hormones,
>
> silicon, etc.)
>
> Sex with transgender (anal or vaginal intercourse).
>
> Sex with female (anal or vaginal intercourse).
>
> Sex with male (anal or vaginal intercourse).
>
> Other (specify)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> No risk identified
>
> Refused to answer

**^®G201,\ ®G202,\ ®G212,\ ®215^What other risk factors did the client
engage in within 90 days that placed the client at potential risk for
HIV exposure and/or transmission?** (Check all that apply.)

> Use of alcohol and/or illicit drugs before or during sex
>
> Sex with a person who is an IDU
>
> Sex with someone who is HIV-positive
>
> Sex with someone whose HIV status is unknown
>
> Sex with someone in exchange for drugs, money, or something that is
> needed
>
> Sex with someone who exchanges sex for drugs/money
>
> Sex with a male known to be MSM **(Ask women only)**
>
> Sex with an anonymous person or whose identity was unknown to client
>
> Sex with someone who has hemophilia or is a transfusion/transplant
> recipient
>
> Sex with someone met on the internet
>
> Received money for engaging in sexual intercourse
>
> Been in jail or prison
>
> Other (specify)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> No risk identified
>
> Refused to answer

**[SUBSTANCE USE RISK FACTORS]{.underline}**

**Current substance use**: Currently using Not using, in recovery

Not using Never used

***IF*** the client has injected in the past 90 days \[from I02\]:

**Does client identify drugs/alcohol as a problem?** No Yes

**Does significant other or family identify drugs/alcohol as a problem
for the client?** No Yes

**Has client had previous substance abuse treatment?** No Yes

If yes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®G214^ Has the client used any of the following injection drugs in
the past 90 days (check all that apply)?**

Heroin and cocaine together Hormones

Heroine alone Steroids

Cocaine alone Silicone

Crack Botox

Amphetamines, speed, ice, crystal Other (specify) \_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Other narcotic drugs Refused to answer

**^®\ I17^** **In the last 90 days, how many times did the client share
needles/syringes?** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Refused to Answer Don't Know

***IF*** the client has shared needles in the past 90 days \[from I17\]:

**^®\ I18^** **Of the times the client shared needles, how many times
did the client share with partners whose HIV serostatus was different
from the client's or whose status was not known to the client?**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Refused to Answer Don't Know

**Has the client used any of the following non-injection drugs in the
past 90 days (check all that apply)?**

Alcohol Amphetamine, meth, speed, crystal, crank

Crack Cocaine (smoked, snorted)

Downers (Valium, Xanax, Altivan) Hallucinogens (such as LSD)

Ecstasy Club drugs (such as GHB, Ketamine)

Heroine (smoked, snorted) Marijuana

Poppers Other (specify)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Don't Know Refused to answer

**If using drugs or alcohol, collect the following information**

Drug of choice Amount/Frequency

1\.

2\.

3\.

Depending on the frequency of drug use, the counselor may want to have a
client further evaluated for substance abuse treatment.

**SUMMARY: SUBSTANCE USE ASSESSMENT (Choose one)**

> Client is currently using drugs/alcohol but does not feel treatment is
> necessary and is not interested in obtaining treatment.
>
> Client is currently using drugs/alcohol and is interested in obtaining
> treatment.
>
> Client is currently in treatment.
>
> Client is currently not using drugs.

**[SEXUAL RISK FACTORS]{.underline}**

Instructions: If the client does not know the exact number, ask him/her
to give an estimate of the number of sexual partners for the questions
below.

**A. Number of sexual partners that were men?** \_\_\_\_\_

**B. Number of sexual partners that were women?** \_\_\_\_\_

**C. Number of sexual partners that were transgender?** \_\_\_\_\_

**^®\ I03^** Add A + B + C to get total sex partners in past 90 days
*\_\_\_\_\_*

**^®\ I06^** **Considering all your sex partners together, regardless of
gender, in the past 90 days, how many times did you have anal/vaginal
sex (both protected and unprotected) with all of these sexual
partners?** \_\_\_\_\_\_\_\_ Refused to Answer Don't Know

**^®\ I08^** **In the last 90 days, how many times did you have
unprotected sex with all of your partners?** \_\_\_\_\_\_\_\_ Refused to
Answer Don't Know

**^\*\ I13^** **Of these unprotected times \[from I08\], how many of
these times were with an injection drug user?** \_\_\_\_\_\_\_\_ Refused
to Answer Don't Know

**^\*\ I14^** **Of these unprotected sex events \[from I08\], how many
of these times were with a partner who you know exchanges sex for money
or drugs?** \_\_\_\_\_\_\_\_ Refused to Answer Don't Know

**^®\ I15^ Of these unprotected sex events \[from I08\], how many of
these times were you drunk or high?** \_\_\_\_\_\_\_\_ Refused to Answer
Don't Know

**[IF I15 is more that zero]{.underline}**

**^®I16^** **Which of the non-injections drugs were used before or
during the sex events described above? (Check all that apply.)**

> 01 Amphetamine, meth, speed, crystal, crank, etc
>
> 02 Crack
>
> 03 Cocaine (smoked, snorted)
>
> 04 Downers (Valium, Ativan, Xanax)
>
> 05 Pain killers (Oxycontin, Percocet)
>
> 06 Hallucinogens such as LSD
>
> 07 Ecstasy
>
> 08 Club drugs such as GHB, ketamine
>
> 09 Heroin (smoked, snorted)
>
> 10 Marijuana
>
> 11 Poppers (amyl nitrate)
>
> 12 Alcohol
>
> 77 Refuse to Answer
>
> 88 Other
> (specify)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> 99 Don't know

Now I would like to ask you about the HIV status of all your sex
partners.

**^®I04^**Number of \"serodiscordant or HIV status unknown sexual
partners.\" To get this number, ask the following questions and then
calculate the total based on the [client\'s]{.underline} serostatus.

(A serodiscordant partner has an HIV serostatus that is different from
the client.**)**

**A. Number of sexual partners who were HIV-positive?** *\_\_\_\_\_\_\_*

**B. Number of sexual partners who were HIV-negative?** *\_\_\_\_\_\_\_*

**C. Number of sexual partners whose serostatus was unknown?**
*\_\_\_\_\_\_\_*

If client is *[HIV-positive]{.underline},* add B + C to get

total number "serodiscordant or HIV status unknown"
*\_\_\_\_\_\_\_\_\_\_\_\_*

OR

If client is *[HIV-negative]{.underline},* add A + C to get

total number "serodiscordant or HIV status unknown"
*\_\_\_\_\_\_\_\_\_\_\_\_*

OR

If client has an *[unknown HIV serostatus]{.underline},* add A + B + C
to get

total number "serodiscordant or HIV status unknown"
*\_\_\_\_\_\_\_\_\_\_\_\_*

**^®\ I05^ If client had unknown serostatus partners \[See I04-C\] in
the past 90 days. How many of**

**your unknown serostatus partners were "anonymous"? \[This means that
the partner's**

> **identity was unknown to the client.\]** *\_\_\_\_\_\_\_\_\_\_\_\_*
> Refused to Answer Don't Know

**^®\ I07^** **Considering all your serodiscordant or serostatus unknown
sex partners (which you just told me was \_\_\_ people \[from I04\]), in
the past 90 days, how many times did you have anal/vaginal sex (both
protected and unprotected) with these people?**
*\_\_\_\_\_\_\_\_\_\_\_\_* Refused to Answer Don't Know

**^®\ I09^How many of these times \[from I07\] with all your
serodiscordant or serostatus unknown sex partners were unprotected?**
*\_\_\_\_\_\_\_\_\_\_\_\_* Refused to Answer Don't Know

**^®\ I10^How many of these unprotected times \[from I09\], were with
male partners?** *\_\_\_\_\_\_\_\_\_\_\_\_*

Refused to Answer Don't Know

**^®\ I11^How many of these unprotected times \[from I09\], were with
female partners?** *\_\_\_\_\_\_\_\_\_\_\_\_*

Refused to Answer Don't Know

**^®\ I12^How** **many of these unprotected times \[from I09\], were
with transgender partners?** \_\_\_\_\_\_\_\_\_\_ Refused to Answer
Don't Know

**Are there things about reducing sexual risk the client would like to
know more about?**

No Yes

If yes, please explain \_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Is there anything about safer sexual practices the client would like
to know more about?**

No Yes

If yes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Does the client feel comfortable disclosing their HIV status to sexual
partner(s)?**

No Yes Sometimes

If no or sometimes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Does the client feel comfortable saying "No" to unprotected sex with
sexual partner(s)?** No Yes Sometimes

If no or sometimes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Does the client feel responsible for preventing self from becoming HIV
positive or infecting others by sexual contact?**

No Yes Sometimes

If no or sometimes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SUMMARY: SEXUAL RISK ASSESSMENT (Choose one)**

Client has minimal to no knowledge of HIV/AIDS/STDS and puts self/others
at risk.

Immediate intervention is needed.

Client has minimal knowledge of HIV/AIDS/STDS, but is not an immediate
risk to self/others.

There is need for prevention education.

Client has adequate knowledge of HIV/AIDS/STDS, no intervention is
needed.

**[III. MENTAL HEALTH]{.underline}**

Adapted from the Substance Abuse and Mental Illness Symptoms Screener
(SAMISS)

See appendix P

**During the last 90 days, was the client ever on
medication/antidepressants for depression or nerve problems?**

> No Yes

**During the past 90 days, was there ever a time when the client felt
sad, blue, or depressed for 2 weeks or more in a row?**

> No Yes

**During the past 90 days, was there ever a time lasting 2 weeks or more
when the client lost interest in most things like hobbies, work, or
activities that usually gives the client pleasure?**

> No Yes

**During the past 90 days, did the client ever have a period lasting 1
month or longer when most of the time the client felt worried and
anxious?**

> No Yes

**During the past 90 days, did the client have a spell or attack when
all of a sudden the client felt frightened, anxious, or very uneasy when
most people would not be afraid or anxious?**

> No Yes

**Has the client had any unusual experiences such as hearing voices or
seeing things that others do not hear or see?**

> No Yes

**During the past 90 days, did the client ever have a spell or attack
when, for no reason, the client's heart suddenly started to race, the
client feel faint, or the client couldn't catch his/her breath? \[If
client reports this happened only during a heart attach or other
physical causes, mark "NO."\]**

> No Yes

If client responded 'yes' to any mental health question above, a more
through mental health evaluation may be needed per your agency's
guidelines.

**How troubled does the client say (s)he has been with mental health
problems in the past 90 days?**

Not at all

Slightly

Moderately

Considerably

Extremely

**Current mental health treatment** No Yes

If yes, specify provider, facility, diagnosis, and medications
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Prior mental health treatment** No Yes

If yes, specify provider, facility, diagnosis, and medications
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Are there any other mental health problems or issues the client feels
are related to how (s)he is feeling or contributing to her/his
behavior?** No Yes

If yes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SUMMARY: MENTAL HEALTH ASSESSMENT (Choose one)**

Client is in immediate need of a mental health evaluation.

Client is in need of a mental health intervention, but the situation is
not critical.

Client is coping well. There is no need for intervention at this time.

**[IV. MEDICAL]{.underline}**

***[All clients regardless of serostatus]{.underline}***

**Place client usually seeks medical care**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Name of client's doctor/health care provider**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Date of last contact with client's doctor/health care provider?**
\_\_\_\_/\_\_\_\_/\_\_\_\_\_ or Don't know

**Does client have any medical conditions (s)he thinks we should know
about?** No Yes

If yes, please explain
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®\ G213^Has the client been diagnosed with syphilis, gonorrhea, or
chlamydia in the past 90 days?**

No Yes - Self report Yes - Laboratory confirmed Not asked Don't know

**Has the client been tested for any other STDs or viral infection in
the past 90 days?**

No Yes Not asked Refused to answer Don't know

**Which STDs or viral infections has the client been diagnosed with in
the past 90 days?**

Type: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Has the
client sought treatment?** No Yes

If yes, how was the diagnosis or treatment confirmed? Self report
Laboratory confirmed

Type: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Has the
client sought treatment?** No Yes

If yes, how was the diagnosis or treatment confirmed? Self report
Laboratory confirmed

**Is the client planning on having any children soon?** No Yes

**If no, is the client or client's partner practicing any form of birth
control?** No (refer) Yes

***[Women Only]{.underline}***

**^®\ G209^Is the client pregnant?** No Yes Not asked Refused to answer
Don't know

**If yes, how far along in weeks is she?** \_\_\_\_\_\_\_\_\_

**^®\ G210^If yes, is she you receiving prenatal care?**

No Yes Not asked Refused to answer Don't know

**Level of satisfaction with health status (Choose one):**

Not at all Slightly Moderately Considerably Extremely

**SUMMARY: MEDICAL ASSESSMENT (Choose one)**

Client has critical, unmet medical needs. Immediate intervention is
needed.

Client has unmet medical needs, but they are not critical. There is a
need for intervention, but the

need is not immediate at this time.

Client does not have unmet medical needs. No need for intervention at
this time.

**[*HIV-POSITIVE CLIENTS*]{.underline}**

**^®\ G208^Is client currently receiving medical care for HIV?**

No Yes Not asked Refused to answer Don't know

Primary care provider
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone number
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Case manager
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone
number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Agency name and address
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**When was the last time the client had a CD4 (or T-cell) count? (Choose
one)**

Never Within the last 3 months Within the last 6 months

Within the last 9 months Within the last year Don\'t know

**What was the CD4 (or T-cell) count at the client's last measurement?
\_\_\_\_\_\_\_\_** or Don't know

**When was the last time the client had a viral load count? (Choose
one)**

Never Within the last 3 months Within the last 6 months

Within the last 9 months Within the last year I don\'t know

**What was the viral load count at the client's last measurement?
(Choose one)**

Undetectable 1,000 to 9,999 More than 30,000

50 to 999 10,000 to 30,000 Don\'t Know

**Has client ever been prescribed HIV antiretroviral (ARV) drug therapy
by a doctor?**

No Yes Not asked Refused to answer Don't know

**If no, does the client know why not?**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Is client currently being prescribed HIV ARV drugs?**

No Yes Not asked Refused to answer Don't know

**If yes**

How many pills is the client supposed to take a day?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How many pills did the client miss taking yesterday?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How many pills did the client miss taking last week?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**If the client missed taking any medication last week, what was the
reason? (Check all that apply.)**

Forgot Tasted bad

Hard to swallow Not feeling good

Side effects Misplaced/lost/left someplace else

Lack of privacy/Embarrassment Cost

Too many pills Other (specify)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Client's understanding of medication?** Thorough Average Basic
Confused

**Has the client ever stopped taking ARV without the doctor's
permission?**

No Yes Not asked Refused to answer Don't know

**If yes, why?** (Check all that apply)

Side effects Do not like taste Lack of funds to buy

Complicated regimen Other (specify)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Is medical provider aware of adherence problems?**

No Yes Not asked Refused to answer Don't know

**What complementary therapies does the client use?**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Is medical provider aware of complementary therapies or other medical
problems?**

No Yes Not asked Refused to answer Don't know

**Barriers to Drug Adherence (Check all that apply)**

Depression / mental health Undisclosed HIV status

Works outside the home Side effects

Alcohol and drug use/abuse Lack of information

Care giving responsibilities Lack of social support

Difficulty getting refills Doubts medication effectiveness

Lack of regular schedule Needs assistance with ADLs

Taste of medication Size of pills

Number of pills

**SUMMARY: DRUG ADHERENCE ASSESMENT (Choose one)**

> Client lacks understanding of medication regimen and has several
> barriers which make adherence difficult. Immediate intervention is
> needed.
>
> Client has minimal understanding of medication regimen and some
> barriers which make adherence more difficult to manage. There is a
> need for intervention within the month.
>
> Client has an adequate understanding and support to maintain
> medication adherence. No intervention s needed.

**[V. Summary of Initial Session, Potential Needs, & Current
Services]{.underline}**

**Reason for seeking CRCS service**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Risk assessment** (i.e., Personal relationships, disclosure, triggers
to unsafe sex / drugs, barriers and protective factors associated with
behaviors related to drugs and sex)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Basic needs**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Living arrangement**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Child / dependent(s) arrangement**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Social support**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Mental health**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Alcohol and substance use**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Perception of client's readiness for changing behavior**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Client's knowledge / attitude / behaviors about HIV and sexual risk**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Medical need**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Medical / drug adherence need for HIV+ clients**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Services client is currently enrolled in**

Type of service \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Agency name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provider name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Telephone
number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Type of service \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Agency name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provider name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Telephone
number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Type of service \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Agency name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provider name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Telephone
number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Type of service \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Agency name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provider Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Telephone
number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Services client may need and is eligible for**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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**Other observations / issues**
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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[VI. REFERRALS AND BRIDGE to PREVENTION PLANS]{.underline}**

**Check all of the issues mentioned by client to counselor**

  -- ------------------- ------------ ------ --- ---------------------------------------- ------------ ------
                         **Referral                                                       **Referral   
                         Made?**                                                          Made?**      

     Injection risk      Yes          No         Stigma                                   Yes          No
     behavior                                                                                          

     Drugs/Alcohol       Yes          No         Assertiveness                            Yes          No

     Sexual risk         Yes          No         Domestic violence                        Yes          No
     behavior                                                                                          

     Disclosure          Yes          No         Mental health                            Yes          No

     Sexual identity     Yes          No         Medical care                             Yes          No

     Partner             Yes          No         Medication adherence                     Yes          No

     Family              Yes          No         STD treatment                            Yes          No

     Relationships       Yes          No         Housing                                  Yes          No

     Work                Yes          No         Referral                                 Yes          No

     Support system      Yes          No         Finances                                 Yes          No

     Isolation           Yes          No         Other**:                                 Yes          No
                                                 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**                

     Stress              Yes          No         Other**:                                 Yes          No
                                                 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**                

     Grief               Yes          No         Other**:                                 Yes          No
                                                 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**                
  -- ------------------- ------------ ------ --- ---------------------------------------- ------------ ------

> **Read: 'We've talked about a lot about you. What do you think are the
> 2-3 most important issues? We'll pick one to work on for right now.'**
>
> **Notes**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_