HIV-Positive Consumer Served
This form is Confidential - Questions? Contact Imagine Hope QA Nurse Tina Gossett, 706.934.5268
Tester Information
Tester's Name
*
First Name
Last Name
Email
*
example@example.com
Agency
*
Please Select
Access Point
Advantage BHS
Alliance Recovery/Athens
Alliance Recovery/Conyers
Alliance Recovery/Decatur
Ascensa
Aspire
Avita
Bridge Health
Brunswich Judicial Circuit Drug Court
CaringWorks
Clayton Center
CSB of Middle Georgia
CSB of Middle Georgia/Ogeechee
CSB of Middle Georgia/Quentin's Place
Coastal Behavioral Health
DeKalb County CSB
The Athens Clinic (DM&ADR)
Douglas County CSB
Fulton County Behavioral Health
Gateway CSB
Georgia Treatment Services
Highland Rivers Health
Highland Rivers Health/Cobb
Lanier Treatment Center
Legacy BHS
MARR Inc.
Med-Mark/Treatment Centers/Chatsworth
McIntosh Trail
Middle Flint
New Beginnings Thomasville
Newport Integrated
New Horizons CSB
North Fulton Treatment Center
Oconee
Odyssey Family Counseling Center
Pathways CSB
Pineland
Pittard Clinic
Recovery Consultants
Recovery Place
Reliance Treatment Center of Statesboro
Ringgold Treatment Center
Serenity BHS
Unison Behavioral Health
Unison Drug Court
Unison MAT
Viewpoint Health
Westcare of Georgia
Cell Number
*
Please enter a valid phone number.
Work Number
*
Please enter a valid phone number.
City/Town
*
I served an HIV-positive consumer on:
*
-
Month
-
Day
Year
Date
If your client was in need of HIV treatment (newly diagnosed or previously diagnosed and fallen out of care) were you able to link them?
*
Yes
No
If you were not able to link a client in need of HIV treatment to care, explain why.
*
Lost to follow-up - provided result
Lost to follow-up - not provided result
Consumer declined to be linked to treatment
Turned over to DPH for investigation but not confirmed linked
Other
Client Information
Year of Birth
*
Client's Sex
*
Male
Female
Transgender: Male to Female
Transgender: Female to Male
Other
Client's Race
*
Black or African American
White
Asian
Native Hawaiian or Pacific Islander
Native American or Alaska Native
Other
Client's Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
List the consumer's risk factors (how do they think they contracted HIV?)
*
Unprotected receptive anal sex
Unprotected receptive vaginal sex
Shared injection needles
Unprotected insertive anal sex
Unprotected insertive vaginal sex
Shared tattoo needle
Sexual Assault/Rape
Unknown
Other
Was Partner Notification Initiated?
*
Yes
No
Drug History
*
If they report not using drugs or alcohol, input N/A
The consumer's drug(s) of choice (former or current)
*
The consumer reports not using drugs or alcohol
Alcohol
Crack Cocaine
Cocaine
Crystal Methamphetamine
Heroin or Other Opioid
Marijuana/Cannabis
Mushrooms/Shrooms
Prescription Drug(s)
Other
If consumer used/uses Prescription Drugs, list drug names below:
*
Submit
Should be Empty: