HIV Community Services Program /
Care Coordination Triage
If you received this in the mail, please complete the following questions and return this in the enclosed envelope. This will help us address needs you have at this time.
Client name: / Date: / /Have you had any problems or delays in getting medication? / No Yes
Have you missed any medical, mental health or substance abuse treatment appointments in the last three months? / No Yes
Do you think your housing is unsafe? / No Yes
Have you been unable to pay for your rent, utilities, transportation or food? / No Yes
Are you uninsured or do you have unpaid medical bills (i.e., collection or
past due notices)? / No Yes
If you use tobacco, would you like to quit? N/A, I don’t use tobacco. / No Yes
Would you like assistance in going back to work? / No Yes
During the past two weeks, have you had little interest or pleasure in doing things? / No Yes
During the past two weeks, have you felt down, depressed or hopeless? / No Yes
Male/male-identified – How many times in the past year have you had 5 or more drinks in a day?
Female/female-identified – How many times in the past year have you had 4 or more drinks in a day? / None 1 or more
How many times in past year have you used a recreational drug or used a prescription medication for non-medical reasons? / None 1 or more
Have you had unprotected sex or shared needles in the past 6 months? / No Yes
Would you like to be notified about health education classes? / No Yes
Would you like to speak to the care coordinator for any other reason? / No Yes
Comments:
Office use only: If “yes” has been answered please refer to CC, indicate below the steps taken:
Referred to CC by phone, date: / Initials:
Referred to CC by e-mail, date: / Initials:
Referred to CC in person, date: / Initials:
CC confirms contact with client, date: / Initials:
Client name
Original: Client chart; Copy: To client Page 2 of 2 OHA 8471 (1/16), replaces OHA 8471M