Comments: Housing New Need Continuing Need Since last (re)assessment, there has been: This is a: No changes Changes Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. Type of housing: Rental Own home Nursing home Hospital Transitional living facility Shelter Living with others Living on streets Living in my car Prison/jail Other: Is your housing stable? If homeless, do you need help Number of people in household Yes No Yes No finding shelter? Who do you live with? Name Relationship DOB (minors) Aware of your HIV status? Yes No Yes No Yes No Is housing subsidized? By whom? How much? Yes No Have you applied for subsidized housing? Where? Yes No Do you have past due Are you under threat If yes to either question, explain: rent/mortgage/utilities? of eviction/shut-off? Yes No Yes No Are you satisfied with current housing? If no, explain: Yes No Do you have adequate furniture and appliances in If no, explain: your home? Yes No How do you describe your neighborhood? (Assess safety, walkability, distance to bus stop, etc.) Comments: Children/Dependents Since last (re)assessment, there has been: New Need Continuing Need This is a: No changes Changes Not a need If are changes and/or this is a new/continuing need, then updates must be provided below. Do you have children? # of children Ages # living with you Yes No If children don’t live with you, where do they Do any of the If yes, what? live? children have special needs? Yes No Have your parental rights been terminated? Do you need assistance with caring for children? Yes No Yes No Do you need assistance with locating parenting classes? Do you need assistance disclosing status to children? Yes No Yes No Have your children been tested for HIV? If yes, how many of your children are HIV-positive? Yes No Clinic they receive HIV medical care Name of HIV medical provider
Comments: Housing Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. Type of housing: Rental Own home Nursing home Hospital Transitional living facility Shelter Living with others Living on streets Living in my car Prison/jail Other: Is your housing stable? Yes No If homeless, do you need help finding shelter? Yes No Number of people in household Who do you live with? Name Relationship DOB (minors) Aware of your HIV status? Yes No Yes No Yes No Is housing subsidized? Yes No By whom? How much? Have you applied for subsidized housing? Yes No Where? Do you have past due rent/mortgage/utilities? Yes No Are you under threat of eviction/shut-off? Yes No If yes to either question, explain: Are you satisfied with current housing? Yes No If no, explain: Do you have adequate furniture and appliances in your home? Yes No If no, explain: How do you describe your neighborhood? (Assess safety, walkability, distance to bus stop, etc.) Comments: Children/Dependents Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If are changes and/or this is a new/continuing need, then updates must be provided below. Do you have children? Yes No # of children Ages # living with you If children don’t live with you, where do they live? Do any of the children have special needs? Yes No If yes, what? Have your parental rights been terminated? Yes No Do you need assistance with caring for children? Yes No Do you need assistance with locating parenting classes? Yes No Do you need assistance disclosing status to children? Yes No Have your children been tested for HIV? Yes No If yes, how many of your children are HIV-positive? Clinic they receive HIV medical care Name of HIV medical provider
ELECTRONIC_Standardized_Michigan_HIV_MCM_Reassessment_Pilot_Tool_2_2016_517966_7.docx