Member Intake Form
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1
2Member Intake Form
Date: __________________
How Did You Hear About Us? ________________________
Name, Last: __________________
First: __________________
M.I: ______
Birth Date: ______/_____/______
Home Ph: (____) ______________
Alt. Ph. (____) ________________
Address: ________________________________
City: __________________
State: ______
Zip: _________
Do you work, rent, own property in West Hollywood
YES
NO
If YES, Address: ______________________________________________________________________________________
May we send you mail at this address? YES
NO
May we identify ourselves on a message?
YES
NO
Email:_______________________________________________________________________________________________
Gender: _______
Orientation: ___________________
Are your sexual partners primarily:
Male
Female
Ethnicity: _____________
Primary Language: ___________
Family/ Household Size: ________
Annual Income: _____________
Occupation/ Source of Income: ______________
Dependent Children: _____
Date of your first HIV Diagnosis:
_____/_____/_____
Viral load as of ________
CD4 count as of _________
HIV/AIDS Status:
HIV +/no symptoms
HIV +/ with symptoms
AIDS /no symptoms
AIDS / with symptoms
How did you contract HIV:
Sexual Contact ______
IV Drug Use ______
Hemophilia/Coagulation Disorder ______
Rate yourself at managing your own healthcare:
Excellent
Good
Fair
Poor
What (if anything) is keeping you from managing your healthcare? _______________________________________________
With whom & where do you access medical care? ____________________________________________________________
What type of medical coverage do you have? _______________________________________________________________
Do you need more knowledge or understanding about HIV/AIDS?
YES
NO
If on HIV Meds, do you take them as prescribed?
Always
Sometimes
Rarely
Never
N/A
Do you need help in setting up a better adherence plan?
YES
NO
Do you need Peer Support?
YES
NO
Substance Use History:
Yes, within past year
Yes, not within past year
No History
Decline to state
Are you currently in treatment for substance use?
YES
NO
If yes, where? _______________________
Are you currently in treatment for mental health issues?
YES
NO
If yes, where? _______________________
Do you have any current risk behaviors?
Unprotected Sex
Crystal Meth Use
IV Drug use
None
Necessary paperwork for eligibility:
Proof of residency: _____________
&
Proof of Diagnosis: ____________
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