Form Hiv-563 - Artas Intake Screening Form (Page 2 of 5) in pdf

Form Hiv-563 - Artas Intake Screening Form Page 2

(INTAKE/SCREENING FORM)

CLIENT ENROLLMENT STATUS (Please check appropriated box)

Newly Diagnosed Client

Previously Diagnosed

Lost to Care

RESIDENCY INFORMATION

Street Address: ________________________________________________________________

City: __________________________________ Zip Code: _______________

State: _________

Do you receive mail here?

Yes

No Email Address: ______________________________

Where can we send mail if needed? _________________________________________________

Phone #: ( ____ ) - ________ - ________

Cell Phone #: ( ____ ) - ________ - ________

Where do you usually hang out? ____________________________________________________

Can we contact you at work?

Yes

N/A

Work #: (_____) - ________ - ________

ALTERNATIVE/EMERGENCY CONTACT 1 (such as family, friend, case manager, etc.)

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

Preferred way to contact:

Phone

Cell

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: _______________________________________________________________________

_________________________________________________________________________________

Employee’s Name: _______________________ (First)_______________________ (Last)

Form HIV-563: ARTAS Intake Screening Form-Page

Form Hiv-563 - Artas Intake Screening Form Page 2