COMPREHENSIVE RISK COUNSELING & SERVICES Table of Contents

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2 COMPREHENSIVE RISK COUNSELING & SERVICES Table of Contents Appendix Sample Client Data Collection Templates Prescreener A Screener B Client Contact Tracking C Initial Assessments. D D1 - Initial Assessment for 90-day recall period D2 - Initial Assessment for 15 & 30 day recall periods Prevention Plan Worksheet & Instructions Page E Case Notes & Instructions Page F Session Activities & Content G Referral Tracking... H Follow-up Assessments I I1 - Follow-up Assessment for 15 & 30 day recall periods I2 - Follow-up Assessment for 90 day recall period Discharge J Sample Quality Assurance Data Collection Templates Client Record Checklist for Supervisor K Folder Checklist for Counselor L Client Survey M Supplemental Resources Examples of Conversational Initial Interview Assessment Questions. N CAGE.. O SAMISS.. P CDQ Q Safety Checklist for Home and Community Visits. R Program Preparation Worksheet. S Case Scenario 1 Carol... T Case Scenario 2 Tony.... U Worksheet for SMART Objectives.. V Tips for Setting Professional Boundaries W A Framework for Supervision. X CRCS/PEMS Crosswalk... Y CRCS Reference List.. Z

3 G200 Date / /20 SAMPLE PRESCREENER TEMPLATE H09 Worker ID G102 Client ID G124 Current G123 Gender G116 Race (Check all that apply) G114 Ethnicity Gender at Birth Male Male American Indian/Alaskan Native Hispanic/Latino Female Female Asian Non-Hispanic Transgender Black or African-American Refused to answer MTF Native Hawaiian/Pacific Islander Don t know FTM White Other Refused to answer Don t know G112 DOB / / G113 Age G121 Do you speak English? No Yes G122 If no, what language? Have you engaged in the following behaviors in the past 90 days? Please check all that apply: Had unprotected sex Had sex while drunk or high Exchanged sex for food, money or housing No risks were identified Sexual orientation G204 HIV test before today Shared injection drug equipment Been diagnosed with an STD Had trouble taking HIV meds as prescribed Other G205 Result of test Straight/Heterosexual No (Refer to testing) Positive Bisexual Yes Negative Lesbian/Homosexual/Gay Refused to answer Refused to answer Refused to answer Don t know (Refer) Don t know (Refer) Don t know Other X703 Was the client given a referral to CRCS? No Yes X703 Was the client given other referrals? No Yes (Type) Name: First Middle Last Other names or nickname Best address for contacting client Street City State Zip Can you be contacted by phone/ /other way? Yes No Home Work Cell Pager Other way H13 Recruitment Source (How client learned about the intervention?) Agency. Advertisement Self Partner Family/Friend Don t know Other - Required in PEMS; * - Optional in PEMS Appendix A Page 1 of 1

4 Sample Eligibility Screener Template G200 Date / /20 H09 Worker ID G102 Client ID H18 Recruitment Source (Type of service agency was providing when client was referred to intervention) Counseling and Testing Health Communication / Public Information PCRS Outreach Health Education/Risk Reduction Intake/Screening Other Don t know (Refer) H13 Recruitment Source (How client learned about the intervention, if no outreach or referrals?) Agency. Advertisement Self Partner Family/Friend Other Don t know *Name of agency making referral (if appropriate) Name First; Middle Last: G124 Current G123 Gender G116 Race (Check all that apply) G114 Ethnicity Gender at Birth Male Male American Indian/Alaskan Native Hispanic/Latino Female Female Asian Non-Hispanic Transgender Black or African-American Refused to answer MTF Native Hawaiian/Pacific Islander Don t know FTM White Other Refused to answer Don t know G112 DOB / / G113 Age I G121 Do you speak English? No Yes G122 If no, what language? Sexual Orientation *G126 Relationship Status Insurance Straight/Heterosexual Single / Never married Private Bisexual Married or partnered Medicaid Lesbian/Homosexual/Gay Married but separated Medicare Refused to answer Divorced VA Don t know Widowed Uninsured Other Not asked Other Other Refused to answer Refused to answer HIV STATUS AND TESTING HISTORY 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) Required in PEMS; * Optional in PEMS Appendix B Page 1 of 3

5 I would like to collect information from you to see if you are eligible for CRCS. I ask these questions of all clients. In the past 90 days, Don t No Yes Decline Know Have you shared unclean works (such as needles or syringes) with someone? G211 Have you had unprotected sex with anyone (male, female, transgender) G212 Have you had sex with someone whose HIV status you did not know? G212 Have you had sex with someone whose HIV status you knew was different from yours? G213 Have you been diagnosed with Syphilis, Chlamydia, or Gonorrhea?... G212 Have you had sex while high on drugs or alcohol?... G212 Have you exchanged sex for money, drugs, shelter, etc.?... If you are HIV-positive and have been prescribed HIV medication, have you had trouble taking your HIV medication as prescribed by your doctor?.... Other (Agency-Specified): The client answered Yes or Don t know to of the questions above. Is client eligible for CRCS? No Yes If eligible, Was CRCS explained to client? No Yes Was confidentiality explained to client? No Yes Will client participate in CRCS? No Yes Were consent/confidentiality forms signed? No Yes Was client given a copy of the consent form? No Yes Did client enroll in CRCS? No Yes If client enrolled: Which language will CRCS be conducted in? English Spanish Arabic Cambodian Cantonese Creole/French Farsi Haika Hindi Japanese Korean Lao Mandarin Russian Tagalog Thai Vietnamese Other (specify) X703 Was the client given a referral(s)? No Yes: Name Does the client already have a case manager? No Yes Not Asked Refused to answer Don t know Required in PEMS; * Optional in PEMS Appendix B Page 2 of 3

6 If yes, what is your Case manager s name Telephone number - - Agency Other names or nickname Best address for contacting client Street City State Zip Can you be contacted by phone/ /other way? Yes No Home Work Cell Pager Other (way) If client did not enroll, please check all reasons that apply No Reason/ just didn t try/ not interested Staff was rude / insensitive No time/too busy/put it off Language barrier Did not like the agency Intake process too complicated Agency hours not good 'Too much trouble / work No transportation Confidentiality issues ' Fear/anxiety Too ill to go ' Lack of trust in provider ' Felt well /did not need service ' Other Length of time client has spent with counselor? Minutes CRCS Counselor Signature Date Required in PEMS; * Optional in PEMS Appendix B Page 3 of 3

7 Sample Client Contact Tracking Template Client Name: Client ID Date Time Counselor Contact Method Contact Outcome Contact Message/Notes Phone Letter Outreach Other Reached Did not Reach Phone Letter Outreach Other Reached Did not Reach Phone Letter Outreach Other Reached Did not Reach Phone Letter Outreach Other Reached Did not Reach Phone Letter Outreach Other Reached Did not Reach Phone Letter Outreach Other Reached Did not Reach Appendix C Page 1 of 1

8 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 1 of 22 (PEMS table & item numbers indicated)

9 SAMPLE INITIAL ASSESSMENT TEMPLATE I. Psychosocial Assessment Page Demographics... 3 HIV status and testing history. 4 Basic needs 4 Independent living 5 Living arrangement Transportation.. 6 Legal issues. 6 Social support 7 II. Risk Assessment General HIV transmission risk factors... 8 Substance use Sexual risk III. Mental Health Assessment IV. Medical Assessment All clients. 16 HIV-positive clients only V. Summary of Initial Session, Potential Needs & Current Services VI. Referrals and Bridge to Prevention Plan. 21 Required in PEMS; * Optional in PEMS Appendix D-1 Page 2 of 22 (PEMS table & item numbers indicated)

10 I. PSYCHOSOCIAL ASSESSMENT DEMOGRAPHICS 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 3 of 22 (PEMS table & item numbers indicated)

11 HIV STATUS AND TESTING HISTORY 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 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 4 of 22 (PEMS table & item numbers indicated)

12 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 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 5 of 22 (PEMS table & item numbers indicated)

13 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 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 Is the client on probation or parole? No Yes Are there other legal issues? No Yes If yes, please explain Required in PEMS; * Optional in PEMS Appendix D-1 Page 6 of 22 (PEMS table & item numbers indicated)

14 SOCIAL SUPPORT Evaluate the strength of the client s social support system by placing a check or place the appropriate response in the box below: Spouse Partner Parent Child Sibling/relative Friends Support group Guardian Church CBO staff Other (specify) Can talk to this person about anything? Can borrow money if needed from this person? Person knows client s HIV status? Level of support? 1= Significant support 2 = Occasional support 3 = Weak/No support NA = Not applicable 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. Required in PEMS; * Optional in PEMS Appendix D-1 Page 7 of 22 (PEMS table & item numbers indicated)

15 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 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 8 of 22 (PEMS table & item numbers indicated)

16 Received money for engaging in sexual intercourse Been in jail or prison Other (specify) No risk identified Refused to answer SUBSTANCE USE RISK FACTORS 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 Heroine alone Cocaine alone Crack Amphetamines, speed, ice, crystal Other narcotic drugs Hormones Steroids Silicone Botox Other (specify) 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)? Required in PEMS; * Optional in PEMS Appendix D-1 Page 9 of 22 (PEMS table & item numbers indicated)

17 Alcohol Crack Downers (Valium, Xanax, Altivan) Ecstasy Heroine (smoked, snorted) Poppers Don t Know Amphetamine, meth, speed, crystal, crank Cocaine (smoked, snorted) Hallucinogens (such as LSD) Club drugs (such as GHB, Ketamine) Marijuana Other (specify) Refused to answer If using drugs or alcohol, collect the following information Drug of choice Amount/Frequency 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. Required in PEMS; * Optional in PEMS Appendix D-1 Page 10 of 22 (PEMS table & item numbers indicated)

18 SEXUAL RISK FACTORS 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 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 11 of 22 (PEMS table & item numbers indicated)

19 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 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, add B + C to get total number serodiscordant or HIV status unknown OR If client is HIV-negative, add A + C to get total number serodiscordant or HIV status unknown OR If client has an unknown HIV serostatus, 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 12 of 22 (PEMS table & item numbers indicated)

20 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. Required in PEMS; * Optional in PEMS Appendix D-1 Page 13 of 22 (PEMS table & item numbers indicated)

21 III. MENTAL HEALTH 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. Required in PEMS; * Optional in PEMS Appendix D-1 Page 14 of 22 (PEMS table & item numbers indicated)

22 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. Required in PEMS; * Optional in PEMS Appendix D-1 Page 15 of 22 (PEMS table & item numbers indicated)

23 IV. MEDICAL ALL CLIENTS REGARDLESS OF SEROSTATUS 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 16 of 22 (PEMS table & item numbers indicated) Women Only 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

24 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, to ,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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 17 of 22 (PEMS table & item numbers indicated)

25 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 Works outside the home Alcohol and drug use/abuse Care giving responsibilities Difficulty getting refills Lack of regular schedule Taste of medication Undisclosed HIV status Side effects Lack of information Lack of social support Doubts medication effectiveness Needs assistance with ADLs 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. Required in PEMS; * Optional in PEMS Appendix D-1 Page 18 of 22 (PEMS table & item numbers indicated)

26 V. Summary of Initial Session, Potential Needs, & Current Services 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 19 of 22 (PEMS table & item numbers indicated)

27 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 20 of 22 (PEMS table & item numbers indicated)

28 Services client is currently enrolled in Type of service Provider name Agency name Telephone number Type of service Provider name Agency name Telephone number Type of service Provider name Agency name Telephone number Type of service Provider Name Agency name Telephone number Services client may need and is eligible for Other observations / issues Required in PEMS; * Optional in PEMS Appendix D-1 Page 21 of 22 (PEMS table & item numbers indicated)

29 VI. REFERRALS AND BRIDGE to PREVENTION PLANS Check all of the issues mentioned by client to counselor Referral Made? Referral Made? Injection risk behavior Yes No Stigma Yes No Drugs/Alcohol Yes No Assertiveness Yes No Sexual risk behavior Yes No Domestic violence Yes No 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 Required in PEMS; * Optional in PEMS Appendix D-1 Page 22 of 22 (PEMS table & item numbers indicated)

30 Sample Initial Assessment Template RISK ASSESSMENT (15 or 30 day recall) G200 Date / /20 H09 Worker ID G102 Client ID 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 I01 What recall period will you be using to ask the client the following questions? [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. This form provides 15/30-day recall items for PEMS only.] 15 days OR 30 days I02 What risk factors did the client engage in within [15 OR 30] 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, 202, 212, 215 What other risk factors did the client engage in within [15 OR 30] 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 Required in PEMS; * Optional in PEMS Appendix D-2 Page 1 of 4 (PEMS table and item numbers indicated)

31 Been in jail or prison Other (specify) No risk identified Refused to answer SUBSTANCE USE RISK FACTORS G214 Has the client used any of the following injection drugs in the past [15 OR 30] days (check all that apply)? Heroin and cocaine together Heroine alone Cocaine alone Crack Amphetamines, speed, ice, crystal Other narcotic drugs Hormones Steroids Silicone Botox Other (specify) Refused to answer I17 In the last [15 OR 30] 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 [15 OR 30] 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 [15 OR 30] days (check all that apply)? Alcohol Crack Downers (Valium, Xanax, Altivan) Ecstasy Heroine (smoked, snorted) Poppers Don t Know SEXUAL RISK FACTORS Amphetamine, meth, speed, crystal, crank Cocaine (smoked, snorted) Hallucinogens (such as LSD) Club drugs (such as GHB, Ketamine) Marijuana Other (specify) Refused to answer Required in PEMS; * Optional in PEMS Appendix D-2 Page 2 of 4 (PEMS table and item numbers indicated)

32 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 [15 OR 30] days I06 Considering all your sex partners together, regardless of gender, in the past [15 OR 30] 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 [15 OR 30] 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 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. Required in PEMS; * Optional in PEMS Appendix D-2 Page 3 of 4 (PEMS table and item numbers indicated)

33 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 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, add B + C to get total number serodiscordant or HIV status unknown OR If client is HIV-negative, add A + C to get total number serodiscordant or HIV status unknown OR If client has an unknown HIV serostatus, 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 15 OR 30 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 [15 OR 30] 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 Required in PEMS; * Optional in PEMS Appendix D-2 Page 4 of 4 (PEMS table and item numbers indicated)

34 Sample Prevention Plan Template Appendix E1 Client Name Client ID# CRCS Counselor Date / /20 Goal 1 Target Date Objective 1 Action Step 1 Action Step 2 Action Step 3 Objective 2 Action Step 1 Action Step 2 Goal 2 Target Date Objective 1 Action Step 1 Action Step 2 Objective 2 Action Step 1 Action Step 2 Client s Signature CRCS s Signature Date Date Appendix E-1 Page 1 of 1

35 Appendix E-2 Page of 1 of 1

36 Sample Case Notes Template Appendix F Name Counselor ID Client ID Date / /20 Format of Session (Check one) Face-to-Face Phone Other Length of session hr(s) minutes Goal # Objective 1 Action Step 1 Action Step 2 Overall progress since last session (Check response) Met goal Some improvement No improvement Relapse Achieved today (Check all that apply) Goals and objectives identified Barriers identified Objectives and Action steps developed Other service(s) provided Referrals (Check all that apply) Need identified Referral made during the session Client to contact referral source Referral forms were completed Follow up on previous referral(s) (if any) Completed Did not complete Case Notes CRCS signature Date - Required in PEMS Appendix F Page 1 of 2

37 Instructions for Sample Case Notes Template Appendix F2 This form can be used to record all interactions with clients, but particularly during visits when the client's risk-reduction goals are first identified, as well as during any follow-up visits in which goals are discussed. Depending on the client's needs, counselors should help the client focus on no more than three goals at a time. The client s ID number will be assigned by the agency. The counselor checks the format of the session with the client.. The Overall Progress item is related to the activities the clients are engaged to meet their goals. The counselor s impression of change in clients behavior from the previous session to the current one is also considered when circling a response. This item is not completed the first session. If more specialized help is needed to address identified needs (e.g., substance abuse or primary medical care), referrals should be made and referral forms completed. Counselor should always sign progress (case) notes form after completing it. Signature should be directly under where counselor completes notes of session. Name: Comprehensive ` Risk Counseling and Services Sample Case Notes Template Appendix F1 Client ID #: Counselor ID# Date: / / 20 Format of Session (Check one) Face to Face Phone Other: Length of Session hr(s) minutes Goal # Objective 1 Action Step 1 Action Step 2 Overall progress since last session: (Check response) Met goal Some Improvement No improvement Relapse Achieved today: Goals an objectives identified Barriers identified Objectives and Action steps developed Other service(s) provided: Referrals (Circle all responses) Need identified Referral made during the session Client to contact referral source Referral forms were completed Follow-up on previous referral(s))( if any) Completed Did not complete Case notes Case notes should be written in this space. Types of information that should written in this section includes: client s chief problem(s) in his/her own words, counselor s insights and observations, goals, objectives, action steps, barriers, level of functionality, assessment information, incentives (type and reason for it), and other data collected during the session. The back of the page can be used if additional space is needed. CRCSs Signature: The session date is the actual date of the counseling session. The goal number and description, along with objectives and action steps, are copied from the prevention plan. There can be more than one objective for each goal. Objectives and action steps may be modified from session to session This information should be completed after each session for each goal addressed. The Achieved Today item is related to the the development, review, and modification of the Prevention Plan. A list of other services or information not listed on form should be written here. Counselor should inquire about completion of any referrals given at any session (if appropriate). - Required in PEMS Appendix F Page 2 of 2

38 Sample Session Activities and Content Template Name H06 Date / /20 H09 Worker ID Client ID H23 A. Contact with Client Type of contact H10 Place of contact H11 Duration of meeting with client 1.00 In person/ Site Name Minutes 2.00 Internet Site zip code 3.00 Printed material 3.02 (Brochures/pamphlets) 4.00 Radio 5.00 Telephone 6.00 Television 7.00 Video 88 Other (specify) H05 Session visit number for CRCS H21 Was client given an incentive for this visit? ' Yes ' No H22 In what manner was CRCS delivered? CRCS is an individual level intervention although clients can be referred to additional activities such as support groups. Check all of the services provided to the client during the session H Table in PEMS H20 B. Other Services provided HIV testing Referral Personalized risk assessment Elicit partners H20 C. Information: Verbal or Printed Materials HIV/AIDS transmission Negotiation/Communication 08.02Abstinence/postpone sexual activity Decision making 08.03Other STDs Disclosure of HIV status 08.04Viral Hepatitis Providing prevention services Availability of HIV/STD C & T HIV testing Availability of partner notification Partner notification and referral services Living with HIV/AIDS HIV medication therapy adherence Availability of social services Alcohol and drug use prevention 08.09Availability of medical services Sexual Health Sexual risk reduction Other (specify) IDU risk reduction Other (specify) IDU risk free behavior Other (specify) Condom/barrier use - Required in PEMS Appendix G Page 1 of 2

39 H20 D. Demonstrations H20 E. Practice Condom/barrier use Condom/barrier use IDU risk reduction IDU risk reduction Negotiation/Communication Negotiation/Communication Decision making Decision Making Disclosure of HIV status Disclosure of HIV Status Providing prevention services Providing prevention services Partner Notification Partner Notification Other (specify) Other (specify) H20 F. Discussion with client Sexual risk reduction IDU risk HIV testing Other STDs Disclosure of HIV status Partner notification HIV med therapy adherence Abstinence/postpone sexual activity IDU risk free behavior HIV/AIDS transmission Viral hepatitis Living with HIV/AIDS Availability of HIV/STD C&T Availability of partner notification and referral services Availability of social services Availability of medical services Condom/barrier use Negotiation/Communication Decision making Providing prevention services Alcohol and drug use prevention Sexual Health Other (specify) Other (specify) H20 G. Additional Testing Other testing Pregnant Other testing - STD Other testing Viral Hepatitis H20 H. Distribution H20 I. Post-Intervention Services Male condoms Post-Intervention Follow-up Female condoms Post-Intervention booster session Safe sex kits 88. Other (specify) Safer injection/bleach kits Lubricants H20 J. History Survey Education materials HIV testing history survey Referral lists 88 Other (specify) Role model stories Other (specify) - Required in PEMS Appendix G Page 2 of 2

40 Sample Referral Tracking Template Name X702 Date of Referral / /20 H09 Worker ID Client ID (Fill out 1 form for each referral) X703 Referral Service Type 01 HIV Testing 02 HIV Confirmatory test 03HIV prevention counseling 04 STD screening and treatment 05 Viral Hepatitis screening / treatment 06 Tuberculosis testing 07 Syringe exchange services 08 Reproductive health services 09 Prenatal care 10 HIV medical care / evaluation / treatment 11 IDU risk reduction services 12 Substance abuse services 13 General medical care 14 Partner counseling and referral services 15 Mental Health Services 16 Comprehensive Risk Counseling & Services 17 Other prevention services 18 Other support services 88 Employment Assistance 88 Foodbank 88 Case Management (e.g., Ryan White, SAMSA, Medicaid) 88 Housing Assistance 88 Legal Assistance 88 Child care assistance 88 Clothing assistance 88 Other (specify) Referral Agency Name X705 Referral Follow-up Plan 00 No- follow-up There is no plan to verify that the client accessed this referral 01 Active referral The referring provider will directly link the client to the service provider or agency 02 Passive referral The referring provider will confirm the outcome of a referral through information received by (agency verifies) the receiving agency. 03 Passive referral The referring provider will confirm the outcome of a referral through information provided by (client verifies) the client. X706 Referral Outcome 01 Pending The referring agency has not yet confirmed whether the client accessed the service to which he or she was referred. 02 Confirmed The referring agency has confirmed whether the client accessed the service to which he or she was referred. 03 Confirmed The referring agency has confirmed that the client had not accessed the service to which he or she was referred. 04 Lost to follow-up Within 60 days of the referral date (Referral Date < 60), access of the service to which the client was referred can t be confirmed or denied. The system will automatically mark a referral as lost to follow-up if a referral has not been verified within 60 days of the referral date. 05 No follow-up The referral was not tracked to confirm whether the client accessed the referred service. X710 Referral Close Date The date the outcome of the referral was confirmed or lost to follow-up. / /20 - Required in PEMS; * - Optional in PEMS Appendix H Page 1 of 2 All PEMS items are found in Table X-7.