PAST DATES TREATMENT MODALITY TREATMENT FACILITY COMPLETED? Yes No Yes No Yes No What are some reasons or barriers that prevented you from completing treatment? Yes No Are you currently in substance abuse treatment? If yes, complete chart below. TREATMENT MODALITY DATE COMMENTS Stop smoking program Methadone maintenance Detox Inpatient substance use program Outpatient substance use program AA/NA or other self-help group TREATMENT PROGRAM (ADDRESS/PHONE) TREATMENT COUNSELOR DATE WHEN TREATMENT ENDS Yes No Does your substance use prevent you from going to medical appointments and/or taking your medications? Are you in recovery? What has been your longest period of abstinence? Yes No What has helped you remain in recovery? What are your relapse triggers? If client is actively using substances, answer the following questions: If you inject substances, describe how you keep yourself safe from further injection-related harm? Do you utilize a needle exchange? Do you have a history of overdosing? Are harm reduction methods being Yes No Yes No Yes No used? (Alcohol use) Do you have a history of Would you like assistance to connect If no, are you interested in a referral? Delirium Tremens (DT)? with Partner Services? Yes No Yes No Yes No Are you interested in stopping drug Would you like a referral to substance Are you interested in learning more use? use treatment? about overdose prevention and/or harm reduction? Yes No Yes No Yes No Comments: HIV Prevention and Risk Reduction 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. Are you sexually active? How many sexual partners have you had How do you meet your sexual partners? (Online, Yes No within the past 2 months? bathhouses, clubs, friends, etc.) What are the genders of your sexual partners? Describe how you negotiate safer sex for yourself and your partners. Male Female Transgender (Condoms, viral suppression, serosorting, etc.) Other: Are you currently virally Do your HIV negative partners have If yes, describe how you negotiate PrEP with your suppressed? access to PrEP prevention supplies? partners: Yes No Yes No
PAST DATES TREATMENT MODALITY TREATMENT FACILITY COMPLETED? Yes No Yes No Yes No What are some reasons or barriers that prevented you from completing treatment? Are you currently in substance abuse treatment? Yes No If yes, complete chart below. TREATMENT MODALITY DATE COMMENTS Stop smoking program Methadone maintenance Detox Inpatient substance use program Outpatient substance use program AA/NA or other self-help group TREATMENT PROGRAM (ADDRESS/PHONE) TREATMENT COUNSELOR DATE WHEN TREATMENT ENDS Does your substance use prevent you from going to medical appointments and/or taking your medications? Yes No Are you in recovery? Yes No What has been your longest period of abstinence? What has helped you remain in recovery? What are your relapse triggers? If client is actively using substances, answer the following questions: If you inject substances, describe how you keep yourself safe from further injection-related harm? Do you utilize a needle exchange? Yes No If no, are you interested in a referral? Yes No Do you have a history of overdosing? Yes No Are harm reduction methods being used? Yes No (Alcohol use) Do you have a history of Delirium Tremens (DT)? Yes No Would you like assistance to connect with Partner Services? Yes No Are you interested in stopping drug use? Yes No Would you like a referral to substance use treatment? Yes No Are you interested in learning more about overdose prevention and/or harm reduction? Yes No Comments: HIV Prevention and Risk Reduction 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. Are you sexually active? Yes No How many sexual partners have you had within the past 2 months? How do you meet your sexual partners? (Online, bathhouses, clubs, friends, etc.) What are the genders of your sexual partners? Male Female Transgender Other: Describe how you negotiate safer sex for yourself and your partners. (Condoms, viral suppression, serosorting, etc.) Are you currently virally suppressed? Yes No Do your HIV negative partners have access to PrEP prevention supplies? Yes No If yes, describe how you negotiate PrEP with your partners:
ELECTRONIC_Standardized_Michigan_HIV_MCM_Reassessment_Pilot_Tool_2_2016_517966_7.docx