Comments: Housing Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. Type of housing: Rental Own home Nursing home Hospital Transitional living facility Shelter Living with others Living on streets Living in my car Prison/jail Other: Is your housing stable? Yes No If homeless, do you need help finding shelter? Yes No Number of people in household Who do you live with? Name Relationship DOB (minors) Aware of your HIV status? Yes No Yes No Yes No Is housing subsidized? Yes No By whom? How much? Have you applied for subsidized housing? Yes No Where? Do you have past due rent/mortgage/utilities? Yes No Are you under threat of eviction/shut-off? Yes No If yes to either question, explain: Are you satisfied with current housing? Yes No If no, explain: Do you have adequate furniture and appliances in your home? Yes No If no, explain: How do you describe your neighborhood? (Assess safety, walkability, distance to bus stop, etc.) Comments: Children/Dependents Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If are changes and/or this is a new/continuing need, then updates must be provided below. Do you have children? Yes No # of children Ages # living with you If children don’t live with you, where do they live? Do any of the children have special needs? Yes No If yes, what? Have your parental rights been terminated? Yes No Do you need assistance with caring for children? Yes No Do you need assistance with locating parenting classes? Yes No Do you need assistance disclosing status to children? Yes No Have your children been tested for HIV? Yes No If yes, how many of your children are HIV-positive? Clinic they receive HIV medical care Name of HIV medical provider
Do you need assistance with your children’s HIV medical care/medications? Yes No What is your relationship with children? Do you have other dependents? Yes No # of dependents Ages # living with you If dependents do not live with you, where do they live? Do you need assistance in caring for adult dependents? Yes No What is your relationship with dependents? Comments: Finances and Benefits Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. INCOME AND EXPENSES Do you have income? Yes No If yes, complete chart below: MONTHLY INCOME AMOUNT MONTHLY EXPENSES AMOUNT Employment/wages (gross amount) Rent/mortgage Unemployment Utilities Alimony/child support Phone Pension or retirement income Food Social Security Retirement Insurance premiums Worker’s compensation Medical expenses Social Security Disability Income Medication expenses Supplemental Security Income Car payment FIP/TANF Transportation State Disability Assistance Veteran’s Benefits Other: Other: Other: Other: Other: Other: TOTAL: TOTAL: MONTHLY INCOME – EXPENSES Comments: EMPLOYMENT/DISABILITY Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below.
(For MCM to answer) Based on the above information, rate the client’s level of HIV knowledge: Excellent Very Good Good Fair Poor How often do you need help reading the following: Written information about how to take care of yourself? Always Sometimes Never Written information about how to take your medications? Always Often Sometimes Never Witten information medication side effects? Always Often Sometimes Never Appointment notifications and reminders? Always Often Sometimes Never Treatment information from your dietician, MCM, or mental health/substance abuse counselor? Always Often Sometimes Never How often do you need help with the following: Figuring out the time to take medications? Always Often Sometimes Never Figuring out if you need to eat with medications? Always Often Sometimes Never Understanding your medical provider when he/she talks about your health? Always Often Sometimes Never Being able to effectively communicate your needs to your medical provider? Always Often Sometimes Never Being able to effectively negotiate your health care? Always Often Sometimes Never Discussing your insurance with your clinic’s billing office? Always Sometimes Never Discussing your benefits with your insurance plan? Always Often Sometimes Never Filling out your medical forms by yourself? Always Often Sometimes Never Comments: Health and Medical Care Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If are changes and/or this is a new/continuing need, then updates must be provided below. MEDICAL APPOINTMENTS Are you in medical care? Yes No If yes, complete chart below: TYPE OF PROVIDER NAME CLINIC NAME ADDRESS/PHONE LAST APPOINTMENT NEXT APPOINTMENT Primary Care Kept Missed Rescheduled Infectious Disease Kept Missed Rescheduled Other: Kept Missed Rescheduled Kept Missed Rescheduled How are your appointments with the ID provider? More often than once a month Once every month Once every 2-3 months Once every 6 months Other:
PAST DATES TREATMENT MODALITY TREATMENT FACILITY COMPLETED? Yes No Yes No Yes No What are some reasons or barriers that prevented you from completing treatment? Are you currently in substance abuse treatment? Yes No If yes, complete chart below. TREATMENT MODALITY DATE COMMENTS Stop smoking program Methadone maintenance Detox Inpatient substance use program Outpatient substance use program AA/NA or other self-help group TREATMENT PROGRAM (ADDRESS/PHONE) TREATMENT COUNSELOR DATE WHEN TREATMENT ENDS Does your substance use prevent you from going to medical appointments and/or taking your medications? Yes No Are you in recovery? Yes No What has been your longest period of abstinence? What has helped you remain in recovery? What are your relapse triggers? If client is actively using substances, answer the following questions: If you inject substances, describe how you keep yourself safe from further injection-related harm? Do you utilize a needle exchange? Yes No If no, are you interested in a referral? Yes No Do you have a history of overdosing? Yes No Are harm reduction methods being used? Yes No (Alcohol use) Do you have a history of Delirium Tremens (DT)? Yes No Would you like assistance to connect with Partner Services? Yes No Are you interested in stopping drug use? Yes No Would you like a referral to substance use treatment? Yes No Are you interested in learning more about overdose prevention and/or harm reduction? Yes No Comments: HIV Prevention and Risk Reduction Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. Are you sexually active? Yes No How many sexual partners have you had within the past 2 months? How do you meet your sexual partners? (Online, bathhouses, clubs, friends, etc.) What are the genders of your sexual partners? Male Female Transgender Other: Describe how you negotiate safer sex for yourself and your partners. (Condoms, viral suppression, serosorting, etc.) Are you currently virally suppressed? Yes No Do your HIV negative partners have access to PrEP prevention supplies? Yes No If yes, describe how you negotiate PrEP with your partners:
What HIV/STD prevention methods do you use when having sex? Condom Dental dam Saran Wrap Latex gloves Withdrawal Other: Do you have access to barrier methods (e.g. condoms)? Yes No (For MCM to answer) Can client describe the proper use of condoms? Yes No I may not use barrier methods when: When I am sexually excited When I feel angry or upset When I am with a new partner When I am the top When I am the bottom When I am drinking and/or high When I feel bad about myself Condoms don’t feel good When I am seeking drugs/money When there’s not much risk When I’m undetectable When I’m not expecting sex When my partner pressures me to not use condoms When my partner(s) are Other: How often do you disclose your HIV status with sexual partners? Is there anything about safer sex or sexual risk that you want to know more about? Yes No If yes, describe: (For MCM to answer) Is the client of the Michigan HIV Disclosure law? Yes No If no, did the MCM make client aware of the law? Yes No Would you like assistance to connect with Partner Services? Yes No Has your partner(s) been tested for HIV? Yes No Do you need assistance to access HIV testing? Yes No Comments: Social Support and Spirituality Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. What do you do to socialize? What are your interests? What type of support system do you have? None Family Friends Religious group Support Neighbors Social Media Other: Do you believe you have an adequate support system? Yes No Have you told anyone about your HIV status? Yes No If yes, complete chart below: NAME OF SUPPORT PERSON RELATIONSHIP SUPPORTIVE OF YOU TAKING MEDICATIONS AND TO MEDICAL APPOINTMENTS? Yes No Yes No Yes No Yes No Yes No Who helps you when you are seriously ill? Do you need help to disclose your HIV status? Yes No If yes, who? Is religion/faith/spirituality important to you? Yes No If yes, explain: List 3 strengths or positive areas in your life. How do these strengths help you deal with your diagnosis?