Outreach Encounter Form
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1OUTREACH ENCOUNTER FORM
Outreach Staff Conducting Outreach Encounter
Date of Encounter: ________ / _________ / _________
(circle all that apply):
MO XX
DAY XX
YR 20XX
Peer outreach worker
Non-peer outreach worker
Outreach Worker(s) Initials: ______________________
Case worker
Social worker
Number of Outreach Workers: ___________________
Mental health clinician
Substance use counselor
Nurse
Location of Outreach Encounter (check one):
Physician
Agency
Nurse practitioner
Mobile van
Administrative staff
Streets, parks, open space
Client volunteer
Shelter
Staff volunteer
Apartment building
Other (specify):
Treatment program setting
Correctional institution
Duration of Contact (check one):
Community/entertainment venue (bar, club,
Attempted contact
drop-in center)
<5 minutes
Other (specify):
6–4 minutes
Not applicable/Not face-to-face (specify):
15–29 minutes
30–59 minutes
60–90 minutes
Purpose/Content of Outreach Encounter (check all that apply):
90–120 minutes
Provide information about agency program(s)/resource(s)
Community/entertainment venue (bar, club,
drop-in center)
Provide general HIV information
Other (specify):
Provide specific HIV risk reduction/counseling
Not applicable/Not face-to-face (specify):
Offer HIV testing
Hand out HIV prevention materials (specify):
Type of Contact (check one):
Hand out harm reduction materials (specify):
Face-to-Face
Accompany client to medical appointment
Telephone
Accompany client to other appointment (specify):
Letter
E-mail
Refer or make appointment for medical care (specify):
Other Internet (specify):
Collateral contact:
Refer or make appointment for housing services
Other (specify):
Refer or make appointment for substance use treatment
Community/entertainment venue (bar, club,
Refer or make appointment for mental health services
drop-in center)
Refer to needle exchange
Other (specify):
Refer to make appointment for other services (specify):
Not applicable/Not face-to-face (specify):
Provide medical services (specify):
Client Name or “Street” Name:
Provide mental health counseling (specify):
________________
_________________
________________
First Name
Middle/“Street” Name
Surname
Provide service coordination (specify):
Location Notes: ________________________________________
Provide crisis intervention (specify):
_______________________________________________________
Other Notes: ___________________________________________
Other (specify):
_______________________________________________________
35
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Parent category: Medical