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Instructions to Complete the VCT Intake Form

FILL OUT ONLY IF THIS IS A NEW CLIENT OR CLIENT HAS NOT COMPLETED THIS INTAKE FORM BEFORE. IF THIS IS A RETURN VISIT, FILL OUT THE RETURN VISIT FORM.

Date:

Fill in DD/MM/YYYY for the day you see the client. Ex. 09/09/2003 is the 9th day of September, 2003.

Camp:

Fill in the unique 2-digit code assigned to your camp. The range of codes is 21-32. Codes are listed in the handout VCT Camp and Site Codes. Ex. 24 is Nduta

Site:

Fill in the unique code assigned to your VCT site. The range of codes is A to Z. Codes are listed in the handout VCT Camp and Site Codes. Ex. 21-C is the VCT site in IPD 2 in the Lukole camp.

Counselor:

Print the counselors code and name. Each counselor has a unique code from A to Z. Ex. C - Mujungu

Client code: Fill in the unique 4-digit code assigned to each client. The range for client codes is 0001-9999. Ex. 1234 is client #1234. If the client is returning for a follow-up visit and was registered in the old system: - assign a new code to the client - mark ( X ) in the parentheses following the client code - complete the new intake form AND a return visit form Ex. 1234 (X) is a return client who was registered in the old system. 1234 is the clients new code.

Client seen as:

Tick the appropriate box. If the client is counseled and tested alone, select individual. If the client is counseled and tested with 1 or more partners, select couple. Partners must be present at the same time to be considered a couple.

Partner code:

Fill in the unique 4-digit code assigned to the clients partner. The range of codes is 0001-9999. COMPLETE A SEPARATE FORM FOR EACH PARTNER. If a client brings more than one partner (ex. polygamous relationship), complete a form for each partner. Write the additional partner codes under the Comments section on the clients form. Ex. 1235 is client #1235.

Service requested:

Tick the appropriate box. If the client begins the session ONLY wanting information or counseling without testing, select information or counseling only. If the client changes his/her mind later in the same appointment and decides to test, complete the testing sections but DO NOT change the original service requested answer. If the client wants counseling AND testing, select full VCT. If the client changes his/her mind later in the same appointment and decides against testing, complete the refused testing section found later on the form but DO NOT change the original service requested answer.

Test kits available:

If the client is testing, tick yes if 2 test kits are available or no if 2 test kits are not available on the day the client requests services.

Testing type:

Tick the appropriate box. If the client came to the testing site to request information or testing on his/her own free will, select voluntary. If the client came to the testing center because someone else (pastor, counselor, etc.,) suggested or required it and the client agreed, select consensual.

Sex:

Tick the appropriate box. Select male or female for the gender of the client.

Pregnant:

For women only. Tick yes if the woman is currently pregnant or no if she is not.

# Pregs:

For women only. Fill in the total number of live births, still births, and abortions the woman has had in her life. Ex. 07 is the total number of live births, still births, and abortions of the female client.

Age:

Fill in the age of the client in years. Ex. 32 is the age of the client.

Education:

Tick the appropriate box. Tick only one box. The client need not have completed the level, only attended some school in the level.

Marital status:

Tick the appropriate box. Tick only one box. Married (mon.) is a monogamous marriage and married (pol.) is a polygamous marriage.

Nationality: Tick the appropriate box. If other is selected, write the clients nationality in the space beside or beneath the other box.

Reason service requested:

Tick the appropriate box or boxes. Tick ALL that apply. If the client states that he wants to know his status, probe for the reason(s). If an illness or disease is to be described, please write the description in the space provided. If someone referred the client to VCT, fill in the title of the person in the space provided (exs. my pastor, a doctor), NOT the persons name. If the client states a reason that is not listed, select other and write the reason in the space provided.

How learned about service: Tick the appropriate box or boxes. Tick ALL that apply. If the client states an answer that is not listed, select other and fill in the answer in the space provided.

Condom use steady partner: Tick the appropriate box. A steady partner is the clients spouse or regular sexual partner. If the client and his/her steady partner used a condom the last time they had sex together, tick yes. If not, tick no. If the client has more than 1 steady partner (i.e. polygamous relationship), ask this question for each steady partner. Write the answers for the additional steady partners in the Comments section.

Condom use non-steady partner: Tick the appropriate box. A client may have one or more other sexual partners in addition to a spouse or regular sexual partner. If the client and his/her non-steady partner used a condom the last time they had sex together, tick yes. If not, tick no.

Client ever tested :

Tick the appropriate box. Ever tested means at any time in any location, including the clients native homeland.

Previous result:

Tick the appropriate box. Tick only one box. If the client has never tested before, do not answer this item.

Previous Test date:

Write the month and year the client was last tested.

Client tested today:

Tick the appropriate box. If the client tests, tick yes. If the client does not test, tick no.

If not testing:

Tick the appropriate box. Tick only one box. If the client states a reason that is not listed, select other and write the reason in the space provided. If the client is testing, do not answer this item.

Client test result:

Tick the appropriate box or boxes. If Capillus is negative, do not complete the Determine and Tiebreaker items. If Capillus and Determine are both positive, do not complete the Tiebreaker item. If Capillus and Determine are discordant, tick the appropriate box in the Tiebreaker item.

Date result given:

Fill in DD/MM/YYYY for the date the client receives the test result. Leave this item blank if the client does not receive the test result.

Post-test counseling:

Tick yes if the client received post-test counseling or no if the client did not receive post-test counseling. If no, write the reason in the space provided on the form.

Client received result:

Tick the appropriate box. Tick yes if the client received test results or no if the client did not receive test results. If no, write the reason in the space provided on the form.

Couple discordant:

Tick the appropriate box. If the client and his/her partner are both positive or both negative, select no. If one partner is positive and the other is negative, select yes. In a polygamous relationship, select yes if 1 or more partners is discordant. If the client is testing alone, tick NA.

Referrals:

Tick the appropriate box or boxes. Tick ALL that apply. If a referral is not on the list, select other and write the referral in the space provided.

Comments:

Write notes in the space provided at the bottom or back of the form or on additional sheets attached to the form. Examples: - If a client comes with more than 1 partner, write the additional partner codes here. - Write answers to the condom use question for each additional steady partner here. - Write all other important notes from counseling sessions here.