LOUISIANA POSITIVE CHARGE
[INTAKE / SCREENING FORM]
INTAKE DATE: ___ /___ / _____ (mm/dd/yyyy)
(URN)
Complete URN after filling information in CAREWare System
CLIENT INFORMATION
Client Name: ________________________ (First name) _______________________ (Last Name)
Date of Birth: _____ / _____ / _______ (mm/dd/yyyy) Social security number: ______________________
Highest Educational Level:
Less than 9th grade
Some college, no degree
Master's degree
9th-12th grade (no diploma)
Associate degree
Professional degree
High School graduate
Bachelor's degree
Doctorate degree
Primary Language:
English
Spanish
French
French Creole
American Sign Language
German
Tagalog
Italian
Korean
African Languages
Vietnamese
Client received copy of informed consent
DEMOGRAPHICS: (Please check appropriate boxes)
RACE
Hispanic
White
Black or African American
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native
Unknown/Unreported
Gender:
Male
Transgender Female-to-Male
Female
Transgender Male-to-Female
Non-Hispanic
Unknown
Unknown
Refuse to Respond
Transgender Unknown
CLIENT ENROLLMENT STATUS (Please check appropriated box)
New Louisiana Positive Client Charge
Continuing (out of care)
“Continuing” definition: Client who was enroll in Louisiana Positive Charge before.
CURRENT ENTRY POINT (Please check appropriate box)
CARP / Earl K. Long Medical Center
STD Control Program
N'R Peace / HOP Clinic
NO/AIDS Task Force/OPSO
St. John #5/Camp ACE
Worker's Name:__________________________ (First) __________________________________ (Last)
Page 1
LOUISIANA POSITIVE CHARGE
[INTAKE / SCREENING FORM]
INTAKE DATE: ___ /___ / _____ (mm/dd/yyyy)
(URN)
Complete URN after filling information in CAREWare
System
RESIDENCY INFORMATION:
Street Address: ________________________________________________________________
City: __________________________________ Zip Code: _______________
Phone #: ( ____ ) - ________ - ________
State: __________
Email Address: ______________________________
Cell Phone #: ( ____ ) - ________ - ________
ALTERNATIVE/EMERGENCY CONTACT 1:
Refused
Name: ______________(First name) _______________(Last Name) Relationship: _____________________
Street Address: _____________________________________________________________________
City: __________________________________ Zip Code: _______________
State: ___________
Phone #: ( ____ ) - ______ - ______ Cell #: ( ____ ) - ______ - ______
Email Address: _____________________________________
Is this contact aware of your HIV status?
Yes
No
Preferred way to contact:
Cell
Email
Phone
If preferred way to contact is by calling the alternative/emergency contact's phone or cell phone:
The best time to contact him/her is between ______ to ______ (am) or _______ to _______ (pm)
Comments: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Worker's Name:__________________________ (First) __________________________________ (Last)
Page 2
LOUISIANA POSITIVE CHARGE
[INTAKE / SCREENING FORM]
INTAKE DATE: ___ /___ / _____ (mm/dd/yyyy)
(URN)
Complete URN after filling information in CAREWare
System
ALTERNATIVE/EMERGENCY CONTACT 2:
Refused
Name: ______________(First name) _______________(Last Name) Relationship: _____________________
Street Address: _____________________________________________________________________
City: __________________________________ Zip Code: _______________
State: ___________
Phone #: ( ____ ) - ______ - ______ Cell #: ( ____ ) - ______ - ______
Email Address: _____________________________________
Is this contact aware of your HIV status?
Yes
No
Preferred way to contact:
Cell
Email
Phone
If preferred way to contact is by calling the alternative/emergency contact's phone or cell phone:
The best time to contact him/her is between ______ to ______ (am) or _______ to _______ (pm)
Comments: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Worker's Name:__________________________ (First) __________________________________ (Last)
Page 3
LOUISIANA POSITIVE CHARGE
[INTAKE / SCREENING FORM]
INTAKE DATE: ___ /___ / _____ (mm/dd/yyyy)
(URN)
Complete URN after filling information in CAREWare
System
HIV STATUS: (Please check appropriate boxes)
HIV-positive, not AIDS
HIV-positive, AIDS status unknown
HIV-positive, AIDS
Diagnosis Dates:
HIV: _____ / _____ / _______ (mm/dd/yyyy)
Estimated
AIDS (if applicable): _____ / _____ / _______ (mm/dd/yyyy)
Estimated
HIV Risk Factors (Current): (check all that apply)
Men Who Have Sex with Men
Injection Drug User
Hemophilia/Coagulation Disorder
Heterosexual Contact
Perinatal Transmission
Unknown/Unreported
Transfusion of Blood or Blood Components
Other: _____________________________________________________________________
QUALITY OF LIFE
Would you say that in general your health is:
Excellent
Very Good
Good
Poor
Refused to answer
Don't know *
Fair
* Do not read a aloud
Worker's Name:__________________________ (First) __________________________________ (Last)
Page 4
LOUISIANA POSITIVE CHARGE
[INTAKE / SCREENING FORM]
INTAKE DATE: ___ /___ / _____ (mm/dd/yyyy)
(URN)
Complete URN after filling information in CAREWare
System
CLIENT NEEDS
I am going to read a list of services and resources. Please indicate me which ones you currently need.
(Please indicate which of these services is most urgent for the client now)
Currently
Most Urgent
Need
(Check only one)
Drug and Alcohol abuse treatment
Housing or Shelter
Food or other subsistence needs
Dental Services
HIV-related Medical Services
Non-HIV related Medical Services
Pharmacy or Medication Services (For HIV or non HIV reasons)
Mental Health Services (inpatient or outpatient)
Other: _________________________________________________________
_______________________________________________________________
BARRIERS TO CARE
Often people with HIV face barriers to getting HIV care. What factors make it hard for the client to get
care? (Let the client answer. Do not read the following options; only fill the boxes based on the client’s answers)
Lack of money
Fear
Lack of ancillary services
Homelessness
Stigma
Transportation
Immigration
Denial
Location of care
Incarceration
Distrust of Medical System
Structure of testing
Drug use
Lack of perceived need
Competing priorities
Other: ________________________________________________________________________
Worker's Name:__________________________ (First) __________________________________ (Last)
Page 5
LOUISIANA POSITIVE CHARGE
[INTAKE / SCREENING FORM]
_______________________________________________________________________
INTAKE DATE: ___ /___ / _____ (mm/dd/yyyy)
(URN)
Complete URN after filling information in CAREWare
System
STIGMA
Now I will read you some statements, please tell me how often you have felt this way.
Not at all
Rarely Sometimes Often
I've felt that people avoided me because I have HIV
I've feared I would lose friends if they learned about my HIV
I've thought other people were uncomfortable being with me
because of my HIV
I've avoided getting treatment because someone might find out
about my HIV
POSITIVE CHARGE ENGAGEMENT
How did PC first engage client: (Choose one)
PC street outreach
PC social media
PC peer outreach (other than street outreach)
Site: ______________________
PC access coordinator/patient navigator
__________________________
PC affiliated organization
Zip Code: __________________
Other (Specify) ___________________________
________________________________________
Worker's Name: __________________________ (First) __________________________________ (Last)
Page 6