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HIV-Positive Consumer Served
This form is Confidential - Questions? Contact Imagine Hope QA Nurse Tina Gossett, 706.934.5268
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* Required
Email
*
Your email
Testers First Name
*
Your answer
Testers Last Name
*
Your answer
Agency Name
*
Choose
Access Point - Region 2
Advantage BHS - Region 2
Alliance Recovery/Athens - Region 2
Alliance Recovery/Conyers - Region 3
Alliance Recovery/Decatur - Region 3
Ascensa / St. Jude's - Region 3
Aspire - Region 4
Avita - Region 1
Brunswick Judicial Circuit Drug Court - Region 5
CaringWorks - Region 3
Clayton Center - Region 3
CSB of Middle Georgia - Region 2
CSB of Middle GA - Ogeechee - Region 2
CSB of Middle GA - Quentin's Place - Region 5
Coastal Behavioral Health - Region 5
DeKalb County CSB - Region 3
DM & ADR - Region 2
Douglas County CSB - Region 1
Fulton County Behavioral Health - Region 3
Gateway BHS - Region 5
Georgia Treatment Services - Region 2
Highland Rivers Health - Region 1
Highland Rivers/Cobb County CSB - Region 1
Lanier Treatment Center - Region 1
Legacy BHS - Region 4
Lookout Mountain - Region 1
MARR Inc.- Region 3
Med-Mark Treatment Centers / Chatsworth - Region 1
McIntosh Trail - Region 6
Middle Flint - Region 6
New Beginnings in Thomasville - Region 4
Newport Intergrated - Region 3
New Horizons CSB - Region 6
New Horizons Nexus - Region 6
North Fulton Treatment Center - Region 3
Oconee - Region 2
Odyssey Family Counseling Center - Region 3
Pathways CSB - Region 6
Pineland - Region 5
Pittard Clinic - Region 1
Recovery Place - Region 5
Reliance Treatment Center of Statesboro - Region 5
Ringgold Treatment Center - Region 1
Serenity BHS - Region 2
Unison Behavioral Health - Region 5
Unison Drug Court - Region 5
Unison MAT - Region 5
Viewpoint Health - Region 3
Westcare of Georgia - Region 3
Cell Phone
*
Your answer
Office Phone
*
Your answer
City/Town
*
Your answer
I served an HIV-positive consumer on:
*
MM
/
DD
/
YYYY
The HIV+ client was:
*
Previously diagnosed / self-disclosed
Newly diagnosed by me
Required
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
Required
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:
Consumer Information
Year of Birth
*
Your answer
Consumer's Sex
*
Male
Female
Transgender: Male to Female
Transgender: Female to Male
Non-Binary
Other:
Consumer's Race
*
Black or African American
White
Asian
Native Hawaiian or Pacific Islander
American Indian or Alaska Native
Other:
Required
Consumer'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:
Required
Was Partner Notification Initiated?
*
Yes
No
Drug History
*
If they report not using drugs or alcohol, input N/A
Your answer
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
Other:
Required
If consumer used/uses Prescription Drugs, list drug names below:
Your answer
A copy of your responses will be emailed to the address you provided.
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