Please complete this checklist during the client interview. Ask the client to rate each concern on a scale from 1-4.
1=no concern, 2=somewhat concerned, 3= concerned and 4=very concerned.
Feel free to fill this document out online and save it to your computer before printing or to print it and fill it out by hand.
Sections
- Language Access/Translation Services
- Prevention
- Pre-Exposure Prophylaxis (PrEP)
- Non-occupational Post Exposure Prophylaxis (nPEP)
- STIs and/or Viral Hepatitis (HCV) Services
- Paying for Healthcare
- Finding a Provider
- Housing Assistance
- Food Assistance
- Employment Assistance
- Childcare
- Transportation
- Substance Use/Treatment
- Mental Health Services
- Intimate Partner Violence (IVA) Assistance
- Other Concerns
15 pages