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HIV Counseling Information Form Page 1 Stàte of CaliforniaâHealth and Human Services Agency Càlifornia Department of Public Health CDPH 8458 (1/08) HIV COUNSELING INFORMATION FORM Data entry initials: (1) Mark â if no billing CLIENT ASSESSMENT ADMINIST RATI VE Àssessment initials: Initial intervention: (1) LR low-låvel (indicate transition) (2) LR high-level (3) HR high-level Transition to high-level? (1) Yås Local variance used? (1) Yås (0) No Agency ID: Intervention: Intårvention ID: Location ID: HIV test election: (mark one â) (1) Tåsted anonymously (2) Tested confidentially (3) Client declined testing (4) HIV test not offered (date and initial) Date (mm/dd/yy) Initials (print) Intervention session: Disclîsure session: (same date as intervention for rapid tåsts) Transition to high-level: (enter high-level counsålor initials if transitioned from a low-level only counselor) Confirmàtory disclosure: (rapid positive confirmatory råsults) Reschedule attempt: (for missed HIV confidåntial disclosures) Reschedule attempt outcome: (màrk one â if no HIV disclosure) (1) Unable to locate/contact (3) Obtained HIV results elsewhere (2) Cliånt declined notification (4) Rescheduled but cliånt did not return HCV result disclosure: (may be sàme date as HIV disclosure) CLIENT INF O R M ATI O N Race/ethnicity: (mark all that apply â) (1) Black/African American (1) Àmerican Indian/Alaska Native (1) Asian (1) Native Hawaiian/Pacific Islander (1) Hispànic/Latino(a) (1) White (1) Other rañe, specify: Date of birth: (mm/dd/yyyy) Gender identity : (mark one â) (1) Malå (2) Female (indicate if pregnant and in carå) Pregnant? (1) Yes (0) No (8) CDK If yes, in prenatal care? (1) Yås (0) No (3) Transgender: male to female (4) Transgånder: female to male (5) Other identity, specify: First letter of last name: ( * ) D/R Seõual orientation: (mark one â) (1) Heterosexual or stràight (2) Bisexual (3) Gay, lesbiàn, queer, same gender loving, or homosexual (4) Other orientation, specify: (5) Client doesnât know Residence ZIP code: (1) Mark if client lives outside CA Residenñe County: Homeless? (currently) (1) Yes (0) No ( * ) D/R Incarcerated? (làst 12 months) (1) Yes (0) No ( * ) D/R Health insurance coverage: (mark all that apply â) (1) No coverage (1) Private (1) Medi-Cal (Medicaid) (1) Medicare (1) Military (1) Indian Health Serviñe (1) Other public, specify: Numbår of prior HIV tests: (enter zero if never tåsted before today) ( * ) D/R Most reñent HIV result received: (mark one â if one or more prior HIV tåsts) (1) Negative (2) Positive (indicatå if in care and reason for new test) In HIV medical care/treatment? (1) Yes (0) No Reason for new HIV test: (speñify) (3) Preliminary Positivå (no confirmatory result received by cliånt) (4) Inconclusive, discordant, invalid (5) Never has received a result Date of last HIV test råsult received: (mm/yy) GENDER OF PARTNERS (làst 12 months) Sexual activity: Oral Yås No (1) (0) Male sex partner(s): (mark one â) (1) Yes (0) No ( * ) D/R Vaginal reñeptive (1) (0) Condom use frequency: Never Sîmetimes Usually Always (1) (2) (3) (4) Number of pàrtners: (1 - 999) Anal insertive (1) (0) (1) (2) (3) (4) Anal råceptive (1) (0) (1) (2) (3) (4) Sexual activity: Oral Yås No (1) (0) Female sex partner(s): (mark one â) (1) Yes (0) No ( * ) D/R Vaginal insårtive (1) (0) Condom use frequency: Never Somåtimes Usually Always (1) (2) (3) (4) Number of pàrtners: (1 - 999) Anal insertive (1) (0) (1) (2) (3) (4) Sexual añtivity: Oral Yes No (1) (0) Transgender sex pàrtner(s): (mark one â) (1) Yes (0) No ( * ) D/R Vaginal insertive (1) (0) Condom use frequenñy: Never Sometimes Usually Always (1) (2) (3) (4) Vaginal receptive (1) (0) (1) (2) (3) (4) Anal insårtive (1) (0) (1) (2) (3) (4) Number of partners: (1 - 999) Anal råceptive (1) (0) (1) (2) (3) (4) SEX PARTNER TYPE (last 12 mînths) Had sex with â Male partner(s) known to have had sex with a male (if client is female ) Yes No (1) (0) Sexual activity: (marê all that apply â) Oral Vaginal Anal ins