2025 Client Self-Assessment and Intake Form

Client Self-Assessment and Intake Form

Minority Health Consortium, Inc. 208 E. Clay Street, Suite B. Richmond, VA 23219
CTR #
LabCorp #
MHC Staff Verifying Form Information:
MHC Staff Conducting Test:
MHC Staff Conducting Blood Draw:
Appointment Status:
Was client referred to PreP services or STI/HIV Treatment:
If Other, Where was client referred for PrEP services or STI/HIV Treatment:
Where was client referred for PrEP services or STI/HIV Treatment:
Did client attend first PrEP appointment:
Is client still in a PrEP program:
Date of Last Contact:

MonthDayYear
Today's Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Appointment Date and Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
CLIENT INFORMATION

Demographics
Name*

First NameLast NameSuffix
Preferred Name*
(How would you like to be addressed?)
Preferred Pronouns:*
(Which pronouns do you like for yourself?)
D.O.B.*

MonthDayYear
Date
Current Age*
Age Range:
Address*

Street Address - Please use permanent address no P.O. Boxes or Dormitory Bldg.

Apt #

CityState

County
Zip Code*
Phone Number*
Please enter a valid phone number.
Email*

Confirmation Emailexample@example.com
PHOTO ID:

Current Photo ID required
Would you like to Upload or take a picture:*
Photo ID (FRONT)*
Photo ID (FRONT)*

Cancelof
Photo ID (BACK)*

Cancelof
Photo ID (BACK)*

HIV Information and Consent for HIV Testing Agreement
Testing provided by Minority Health Consortium, Inc. is voluntary. By signing this form, you consent to take a test that will show if you have antigen or antibodies for HIV, the virus that causes AIDS. Every copy of HIV has antigen inside. Your body reacts to the antigen by making HIV antibodies. If you have either antigen or antibodies for HIV, you are likely infected. HIV antigen can be detected before HIV antibodies, so the test may find one and not the other. People get HIV most often by having unprotected sex or sharing needles/syringes with an infected person. If you may have been exposed to HIV in the past three weeks, it is recommended that you test again in one month regardless of your test result. People who often engage in high-risk behavior should test every three months and consider taking Pre-Exposure Prophylaxis, a daily pill that can prevent HIV. Like a number of other communicable diseases, HIV is a reportable condition in the state of Virginia. This means that if you are diagnosed with HIV, your name and contact information will be reported to the Virginia Department of Health. The health department will protect your identity and your records. If you are diagnosed with HIV, Minority Health Consortium, Inc. or the health department will help you access medical care. Receiving HIV-specific treatment is important to protecting your health. With medical care, most people with HIV can have a normal lifespan. Proper HIV medical treatment can also make it impossible for an infected person to pass the virus to someone else.
What Kind of Test Will Be Done?
You are receiving a rapid test. Rapid tests are simple and accurate when performed at point-of-care by personnel trained to follow manufacturer’s instructions. Your test counselor has been specially trained to conduct your HIV test, and will use a fingerstick lancet to collect a blood specimen. The results of your rapid test will be ready in about 15 minutes.

What does my Test Result Mean?

If your rapid HIV test is negative, no antigen or antibodies for HIV were found However if you had unprotected sex or shared needles/syringes in the past three weeks, there is a chance that you may be in the “window period”. This means that you may be infected, but it may be too early for the test to detect any antigen or antibodies in your blood, and you should betested again in one month. If your rapid test is reactive for HIV antigen or antibodies, you will need a confirmatory, or follow-up test, to verify the result of the first HIV test.

Service Navigation Assessment

Your health is and well being are important to us. Please take a few minutes to complete this questionnaire so that we can offer assistance in finding the resources you may need .
1. What health concern and or services would you like help with today?
Please respond Yes or No to the questions below.

Your answers will help us know more about you and how we may be able to help you with your health.
3.Do you have trouble getting to health appointments, your job or other important places?*
4.Are you concerned about losing your current housing, or have you lost your housing?*
5.In the last three months, have you had any "turn-off" notices, disconnections, or evictions notices?*
7.Do you feel safe in your home or where you sleep at?*
8.Do you feel safe in your relationships?*
9.Have you been sad, depressed, anxious or nervous most of the time in the past 30 days?*
10.In the past 30 days, did you consume 4(for females) or 5(for males) alcoholic drinks in one sitting?*
11.In the past 6 months, have you used drugs other than those required for medical reasons?*
Is there anything else you would like us to know?*
Is there anything else you would like us to know?

PrEP and nPEP Questionnaire

Please think about and select the answers to Questions 1-6.Then answer questions A, B and C in the box below the questions.
1.Do you have sex, without using condoms, with people of unknown HIV Status?
1a. If Yes, did you have sex without a condom within the past 3 days (72 hours)?*
2.Do you have sex, with a partner who has HIV?
2a. If Yes, did you have sex with partner who has HIV within the past 3 days (72 hours)?*
3.Have you been diagnosed with syphilis or gonorrhea/chlamydia in the past 6 months?*
4.Do you share needles or "works" with other people for medical or non-medical purposes?*
for example, injecting drugs, hormones, or steroids
4a. If Yes, did you share needles within the past 3 days (72 hours)?*
5.Do you ever agree to have sex with someone because you need something from the other person, like money, housing or drugs?
6. (For Females) are you trying to become pregnant with a male who is HIV Positive?*
A. Did you say "Yes" to any of these statements?*
B.Are you interested in PrEP, the pill that can help prevent HIV?*
C.Did you say "Yes" to 1a, 2a or 4a? (Above)*

Status Neutral Consent Form
I give my permission for VDH to obtain, verify, and/or release my race, ethnicity, address, medical, prescription, and/or insurance coverage information, with other agencies as necessary to manage my medication access and services through the Virginia Ryan White Part B program including the Virginia Medication Assistance Program (Ryan White Part B Program). VDH may share my information with, but not limited to:

physicians, health department personnel, case managers, other Division of Disease Prevention programs (including HIV Surveillance, HIV Care, and HIV Prevention), treatment center personnel, pharmacy services providers, referral sources for services or agencies, clinics, insurance broker, agencies that pay my insurance premiums or medication copayments, and/or insurance carrier. VDH and these entities agree to treat any and all such information as confidential.

I give permission for VDH to release records or information to necessary agencies to support the application or payment by Medicare, Medicaid, other health care benefits, or services through the Ryan White Part B Program.

I have read (or had read to me) the information and permissions. I understand this information and my signature shows my agreement with these conditions for services from the Ryan White Part B Program. I have verified that the information provided in this application is complete and accurate to the best of my knowledge

Client Responsibilities, Understandings, and Rights
• It is my responsibility to provide information, including medical status and proof of income, changes in address, phone numbers, and any changes to my name every six months, to remain eligible for any VA Ryan White Part B Program services including the Virginia Medication Assistance Program (VA MAP) services.

• It is my responsibility to notify Virginia Department of Health (VDH) of any changes in my contact information, income, insurance status, and insurance premium amount (if applicable) at any time these changes occur. If I do not provide the necessary documentation, I understand it will affect whether I can
still receive services through the VDH.

• It is my responsibility to return any checks, cash, or other types of refunds that I receive from any provider if VDH has paid for those services. I understand the money belongs to VDH. This includes checks from
insurance companies. I will return any refund or credit to VDH within seven days of receipt. I understand I can send the payment directly to VDH, I can drop it off to VA MAP staff at VDH, or I can give it to my Ryan White Case Manager or medical provider who will return in to VA MAP/VDH for me. I understand that keeping these refunds, credits, or checks may result in not being able to get services from VA MAP in the future.

• I understand that VDH enters my information into a confidential database that helps the program provide me the services I need.

• I understand that if I do not sign this form, VDH will not share my information. It is then my responsibility to contact each agency individually to give my information to get services. I also understand that if I change providers, such as a medical provider or case manager, it is my responsibility to inform VA MAP.

• I request third party payers to pay any authorized benefits to or for VDH on my behalf, and I will cooperate with these payers to resolve any issues for payment if needed.

• It is my right to receive quality services in a respectful and culturally appropriate manner from any agency that receives Ryan White funding from VDH, including VA MAP services provided directly by VDH. It is also my right to file a complaint against the agency or agencies where I get my services including VDH, if I feel I am not receiving services in this manner. I can file the complaint directly with the agency and understand that they are required to send a copy to VDH. Complaints against VDH may be sent directly to
VDH or to its federal funder.

• It is my right to request information from my providers and VDH about my care. There may be a formal process to follow for each agency for these requests, but I understand I am entitled to ask for this information.

• I understand that I should send all readable or written documents such as grievances, checks from the insurance company, any insurance-related information related to my care, documents to support my eligibility for the Ryan White Part B program, and any changes in my information related to eligibility status to the Ryan White Part B program including VA MAP. The mailing address is Virginia Department of Health, HCS Unit, 1st Floor, James Madison Building, 109 Governor Street, Richmond, VA 23219. The fax number is 804-864-8050. Call 855-362-0658 with any questions. All checks must be sent through the mail. Help us protect your personal health information (PHI) and personally identifiable information (PII) and DO NOT EMAIL INFORMATION.

HIPAA PRIVACY STATEMENT
In accordance with the Health Insurance Portability and Accountability Act (HIPAA) regulation at §164.508, it is VDH’s policy that using and sharing my Protected Health Information (PHI) must be made with my written consent. By signing this form, I give permission to VDH to release records necessary to support my application for payment by Medicare, Medicaid, other health care benefits, and other services under the Ryan White Part B Program. It is VDH’s policy to safeguard my PHI when VDH shares it. VDH agrees to treat all PHI as confidential as required by law [HIPAA at §164.530(c)]. At my request, VDH will provide me with how my PHI was used or shared as required by law [HIPAA Privacy Rule at §164.528 and §164.514(d)(3)]. VDH will also allow me the right to look at and ask for a copy of my PHI for as long as VDH keeps the information. This permission will remain in effect as long as I, and any of my dependents remain in VA MAP, or until I withdraw it at any time, which I must send to VDH in writing as required by law [HIPAA, §164.508(b)(5)]. Send your written request to withdraw your permission to the Ryan White Part B Program Privacy Officer, HCS unit, 1st floor, 109 Governor Street, Richmond Virginia, 23219.

Grievance Procedure and Acknowledgement

The intent of this procedure is to establish a clear and equitable process for individuals receiving services at MHC to formally file grievances against a grant-funded service. The procedure ensures that grievances are handled with fairness and impartiality, leading to a final resolution.
Steps to Filing a Grievance
Parameters
1. A grievance is defined as a contested issue that requires review and resolution.
2. All grievances must first be reported to the MHC Staff Representative, who will forward them to the appropriate staff for review.
3. Grievances related to the allocation of funds or similar issues are not considered valid under this procedure.
4. Only individuals directly involved in the issue at hand may file a grievance.
5. If the grievance remains unresolved after following the Minority Health Consortium (MHC) grievance process, it may be escalated to the Virginia Department of Health’s contract/site monitor.
1. Initial Reporting:
  1. If an issue arises, the client must be referred to the MHC Staff Representative.
2. Grievance Documentation:
  1. The MHC Staff Representative will document the grievance, whether reported in person or via another form of communication.
3. Staff Referral:
  1. After reviewing the grievance, the MHC Staff Representative will forward it to the appropriate staff member for further evaluation.
4. Internal Review:
  1. If necessary, the CEO will meet with the administrative team to discuss the grievance and take the appropriate steps to address and resolve the issue.
5. Client Updates:
  1. Throughout the process, the CEO will keep the client and the principal investigator informed of progress as needed.
6. Once a resolution is reached, the responsible staff member will contact the client with the outcome.
7. Appeals Process: If the client is dissatisfied with the resolution, they may appeal the decision. A third-party MHC Staff Representative will be involved to review the grievance.
8. Final Escalation:
  1. If the client remains unsatisfied after the third-party review, the grievance will be referred to the contract/site monitor at the Virginia Department of Health for a final decision.
9. This procedure ensures transparency, fairness, and adherence to established guidelines for
10. resolving grievances within MHC services.

Consent and Acknowledgement
By signing below: I acknowladge that I have read, understand and agree to all parts of this intake packet.
- HIV Information and Consent for HIV Testing Agreement
- Status Neutral Consent
- PROVIDE CONSENTS AND SIGNATURES
- Client Responsibilities, Understandings, and Rights
- HIPAA PRIVACY STATEMENT
- Grievance Procedure
Do you agree?*

Yes
Signature

Clear
Should be Empty:

Client Self-Assessment and Intake Form

CLIENT INFORMATION

PHOTO ID:

OTHER DEMOGRAPHICS

HOUSING

Insurance

Other Risk Factors

Sexual History in the Past 12 months

HIV Information and Consent for HIV Testing Agreement

What Kind of Test Will Be Done?

Service Navigation Assessment

PrEP and nPEP Questionnaire

Status Neutral Consent Form

Grievance Procedure and Acknowledgement

Steps to Filing a Grievance

Consent and Acknowledgement