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Captures personal contact details, primary language needs, consent options for mail and email, anonymity return address preferences, and key demographics. Includes sections for key contacts, awareness of HIV status, provider listings, referral agencies, education, reading/writing support needs, medication and housing situation, household composition, transportation, food access, legal issues, prevention screening, acuity level, and required documentation checklist with attached evidence items.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/client-intake-form-revised/302365/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/client-intake-form-revised/302365.png","ImageObject",442,249,{"name":88,"@type":89},"Graffin","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What consent options are collected in the intake form?","Question",{"text":108,"@type":109},"The form records consent to send mail and consent to send email, plus whether an anonymous return address is requested. It also asks permission to leave a message and preferred contact methods.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the form capture HIV-related information?",{"text":113,"@type":109},"It asks about HIV status awareness, provider types (HIV/AIDS provider and primary care provider), and testing dates. It also includes a risk category checklist and options for whether the client has CDC-defined AIDS.",{"name":115,"@type":106,"acceptedAnswer":116},"What topics are included in the prevention screening tool?",{"text":117,"@type":109},"The tool covers relationship status and sexual activity, current protection methods against STDs and HIV, history of STDs or hepatitis, last TB skin test results, substance use and treatment history, and risk factors for transmitting HIV/AIDS. It also includes questions about self-harm or physical harm within the past 12 months.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},302365,1790018879,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},3573418547284,"https://eur-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","CLIENT INTAKE  New Client  Updated  Reactivated Client  \nDate: Social Security \\#: Client \\#:  \nPERSONAL INFORMATION  \nPRIMARY LANGUAGE   NEED INTERPRETER  YES  NO  \nSTREET ADDRESS CITY/STATE ZIP  \nALTERNATE ADDRESS CITY/STATE ZIP  \n   COUNTY Preferred Method of Contact PHONE MAIL EMAIL Consent to Send Mail  YES  NO Consent to Send Email  YES NO Email      \nAnonymous return address requested  YES  NO  \n() May we leave message?  YES  NO Message/Day Phone ()   \nHOME PHONE  \nDiscreet message only:  YES  NO May we contact you at work?  YES  NO PHONE ()   \nETHNICITY:  HISPANIC/LATINO NON-HISPANIC/NON-LATINO  \nRACE:  WHITE  BLACK OR AFRICAN AMERICAN  ASIAN  NATIVE HAWAIIAN /PACIFIC ISLANDER  \n AMERICAN INDIAN OR ALASKAN NATIVE  OTHER  \nKEY CONTACTS  \nEMERGENCY CONTACT RELATIONSHIP PHONE NUMBER  \n     ()   \nAWARE OF STATUS?  YES  NO  \nHIV /AIDS PROVIDER  ( )  PRIMARY CARE PROVIDER   ( )   \nDENTAL PROVIDER  (  )   \nBEHAVIORAL HEALTH PROVIDER   ( )   \nREFERRAL AGENCIES    ( )   \nEDUCATION  \nDo you have difficulty reading?  YES  NO Do you  \n\n| have difficulty writing? |  | YES |  | NO |\n| --- | --- | --- | --- | --- |\n\nHighest level of education completed?  \nPlace Client Label Here  \nCase Managers Initials:   \nDate:   \nHIV STATUS  \n HIV positive not AIDS  HIV positive, AIDS status unknown  CDC-defined AIDS  \nDate tested positive   Date of AIDS Dx:    \nRisk Category (Check One)  \n MSM  MSM/IDU  Heterosexual  Unknown  Occupational Exposure  \n IDU  Maternal/Child  Undisclosed  Blood Products  Other  \nNON-HIV RELATED CONDITIONS  \nMEDICATIONS-Including all current medication, prescriptions, over the counter & experimental  \nMEDICATION PURPOSE DOSE FREQUENCY BEGAN/REFILLED  \nDo you need help obtaining medications?  YES  NO  \nHOUSING SITUATION  \n Permanently Housed (Stable)  Temporary Housing (hotel, family, friend, college dorm, etc.)  \n Transitional Housing (Substance Abuse Treatment Program, Transitional Housing Program)  HUD/Section 8  \n Emergency Housing (Shelter, Salvation Army, Etc.)  Medical Facility (Adult Foster Care, Personal Care Home, Skilled  \nNursing Facility, Hospice, Etc.)  Homeless  Other  \nDescribe current situation (Stability, safety, affordability)  \n________________________________________________________________________________  \n________________________________________________________________________________  \nHOUSEHOLD MEMBERS  \nMARITAL STATUS:  MARRIED  SINGLE  DIVORCE WIDOWER  PARTNER  \nNAME RELATIONSHIP TO CLIENT PHONE \\# AWARE OF HIV STATUS  \n       YES NO  \nFAMILY MEMBER(S) WHO ASSIST WITH YOUR CARE  \nYES  \nYES  \nNO  \nNO  \nHOUSEHOLD MEMBERS LIVING WITH HIV  YES  NO WHO?    \nFAMILY DEPENDENT CHILDREN  \nDo you have dependent children?  YES  NO  \nNames/Ages        \nCase Managers Initials:   \nDate:   \nDo you have any issues related to child custody?  YES  NO  \nIf yes please explain:    \nTRANSPORTATION  \nIs transportation available to you?  YES  NO  \nOwn car?  YES  NO Public Transportation  YES  NO   What problems have you encountered with transportation?    \nDoes the client need help obtaining any of the following?  YES  NO  \n Clothing  Food  Food Stamps  Housing  Income  \nAccess to Food Programs?  YES  NO  \nIf yes, which ones?   Other Household/Personal Items (Toiletries, cleaning supplies, etc.)    \nLEGAL ISSUES YES NO  \nDo you have the following (Check all that apply)? Trust Financial Power of Attorney  \nGuardian/Conservator for: Self and/or  \nIf you have a Power of Attorney, who is Power of Attorney?  \nWill Advance Directives of Health Care Dependents  \n()  Phone Number  \nAddress City/State/Zip  \nDo they know your HIV status?  YES  NO Have you ever been arrested?  YES  NO  \nHave you ever been convicted of a felony?  YES  NO  \nDo you have/ever had any restraining orders against you?  YES  NO Have you ever been incarcerated?  YES NO  \nAre you currently on probation/parole?  YES  NO  \nIf yes, name of probation or parole officer/phone:    \nPlace Client Label Here  \nCase Managers Initials:   \nDate:   \nPREVENTION SCREEN","cbCaikegkHd3DUWP","https://ap.wps.com/l/cbCaikegkHd3DUWP","pdf",183142,"English","# Personal Information\n## Key Contacts and Providers\n## Education and HIV Status\n## Non-HIV Related Conditions and Medications\n## Housing Situation and Household Members\n## Transportation, Food, and Legal Issues\n## Prevention Screening Tool\n## Intake Checklist and Documentation","[{\"question\":\"What consent options are collected in the intake form?\",\"answer\":\"The form records consent to send mail and consent to send email, plus whether an anonymous return address is requested. It also asks permission to leave a message and preferred contact methods.\"},{\"question\":\"How does the form capture HIV-related information?\",\"answer\":\"It asks about HIV status awareness, provider types (HIV/AIDS provider and primary care provider), and testing dates. It also includes a risk category checklist and options for whether the client has CDC-defined AIDS.\"},{\"question\":\"What topics are included in the prevention screening tool?\",\"answer\":\"The tool covers relationship status and sexual activity, current protection methods against STDs and HIV, history of STDs or hepatitis, last TB skin test results, substance use and treatment history, and risk factors for transmitting HIV/AIDS. It also includes questions about self-harm or physical harm within the past 12 months.\"}]","Client Intake Form - Revised | PDF",1789792281]