Form Hiv-563 - Artas Intake Screening Form

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(INTAKE/SCREENING FORM)
INTAKE DATE: ___ /___ / _____
(mm/dd/yyyy)
(URN)
CLIENT INFORMATION
Client Name: ________________________
_______________________
(First name)
(Last Name)
Date of Birth: _____ / _____ / _____
Social security number:_________________
(mm/dd/yyyy)
Highest Educational Level:
Less than 9th grade
9th-12th grade (no diploma)
High School graduate
Some college, no degree
Associate degree
Bachelor's degree
Master's degree
Professional degree
Doctorate degree
Military
Technical / vocational training
Primary Language:
English
Spanish
French
American Sign Language
Vietnamese
German
Italian
Korean
African Languages
Client received copy of informed consent
DEMOGRAPHICS (Please check all that apply)
Race
Hispanic
Non-Hispanic
Unknown
White
Black/African American
Asian
Native American/Alaskan
Pacific Islander/Native Hawaiian
Other
Refuse to Respond
Gender:
Male
Transgender Female-to-Male
Unknown
Female
Transgender Male-to-Female
Refuse to Respond
Transgender Unknown
Sexual Orientation:
Do you consider yourself to be…?
Heterosexual/Straight
Gay/Lesbian
Bisexual
Other: ______________
Respondent does not understand responses
Refuse to Respond
Employee’s Name: _______________________ (First) _______________________ (Last)
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Form HIV-563: ARTAS Intake Screening Form-Page

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