Section 3Assessing Clients’ NeedsFORMS IN THIS SECTION Intake-Assessment Packeto Case Management IntakeAssessment Formo Addictions Support Assessmento Mental Health Assessment Form(for mental health professionals)o Medical Diagnosis Formo HIV Benefits Screening Form(MA specific)RELEVANT STANDARDS OF CARE Needs Assessment Residents’ Records Medication Protocols and AdherenceSupport

Introduction to Section 3SECTION DESCRIPTIONThis section contains an intake-assessmentpacket. The individual sample forms thatmake up the comprehensive packet and areintended to be viewed together feature thefollowing topics:case t, medical diagnosis, and HIVbenefits screening in Massachusetts.These documents are typically used ingathering information about the specificneeds of an individual AFTER s/he hasbeen accepted into housing.Emphasis is given to the word AFTERbecause the Standards of Care encourageprograms to divide the steps of anapplication process into two distinctphases: Tenant Selection (limited to legallyappropriatequestionsandinvestigations) and Needs Assessment (a more extensiveexploration of significant issues, notappropriate for tenant selection, butnecessary for the provider tounderstand in order to serve the newresident well).This division of steps allows the providerto avoid inappropriately introducinginformation gleaned from the needsassessment process in making tenantselection. This also assures that decisionswill be consistent with fair housing anddiscrimination laws. See Section I: TenantSelection for more information about theconsiderations of tenant selection.The needs assessment evaluates theclient’s service related needs withaccuracy and sensitivity. It serves as thebasis for developing an initial individualservice plan for ensuring the quality of theoverall care to be provided.Ongoing reassessments are conducted on aregular and pre-scheduled basis. Theintended outcome is for residents toreceive supportive housing services from aprovider who has sufficient currentinformation to fully understand theresidents’ needs and preferences.An additional assessment that providersare encouraged to perform is a BriefBehavioral Risk and Health Assessmentfor people living with HIV/AIDS. Thepurpose of this assessment, which can beperformed at intake and on an on-goingbasis, is to incorporate positive preventionand harm reduction strategies into day today case management. A Brief BehavioralRisk and Health Assessment for peopleliving with HIV/AIDS tool will beavailablefromtheMassachusettsDepartment of Public Health AIDS Bureauweb site in January 2005.MORE EXPLANATIONSOME OF THE FORMS:ONMost programs utilize a number of formsthroughout the intake process. Therefore,the intake process can be lengthy. Someintake workers choose not to introducepaperwork until the latter part of thismeeting to give the contact a lessbureaucratic tone. Another strategy is totake notes pertaining to a resident’s historyon a notepad and later transfer it to thenecessary forms.However the intake worker chooses tocollect background information on theclient, it may be helpful to prepare theSection 3 – Page 2

client by explaining that the informationbeing collected: is being asked of everyone entering intothe program and not only of him/her can be personal in nature will be kept in strict confidence will not be used to terminate the client will be used to maximize the value ofthe services providedcovers current benefits available inMassachusetts. Programs should consultwith experts in their state to develop asimilar list of benefits for use in theirprograms.Finally, some programs find that clientswill more willingly and honestly answerquestions of a personal nature after theyhave begun to develop a relationship withthe program and program staff. Therefore,it may be helpful to evaluate theimmediacy of the questions being askedon a case by case basis.The Standards of Care are recommendedbest practices that have been establishedin every area of the provision of housingand supportive services. Standards thatare particularly relevant to the topics inthis section are identified and explainedbelow.Case Management Intake FormThe actual intake meeting or meetingsusually involve the completion of asignificant portion, if not all, of this form.Addictions Support Assessment FormThe intent of this form is to assess theclient’s need for and willingness toparticipate in addictions/recovery supportservices. This assessment is sometimesconducted by a specialist in the field and,at others times, is conducted by a generalstaff member with an appreciation forchallenges associated with obtaininginformation about substance using habits.MORE INFORMATION ABOUTKEY ELEMENTS OF THESTANDARDS OF CARE:STANDARD: Needs AssessmentsThe service provider develops a needsassessment tool to be used consistentlywith all residents.The nature of information explored inthe needs assessment will vary fromprogram to program but, may include:medical history and current healthstatus; mental health and emotionalhealth; substance abuse history andcurrent status; functional and cognitiveability; emotional and spiritual needs;assessment of support systems; legaland financial needs.Mental Health Assessment FormThis form may best be administered by amental health professional, one who canmake an assessment of the resident’scurrent mental status.Needs assessments are conducted bystaff members with an appreciation forthe challenges associated withcollecting this kind of information.HIV Benefits Screening FormThis form assists program staff persons indetermining if residents are receiving allof the HIV-related benefits for which theyare eligible. Benefits such as insuranceand medication coverage vary greatly fromstate to state; the form included hereAccording to the Standards, it is theresponsibility of the housing providerto ensure that the initial assessment isupdated as the status and needs of theresident change. At a minimum theassessment is updated every sixmonths. Regardless, it is always doneSection 3 – Page 3

prior to the development of a revisedService Plan.STANDARD: Residents’ RecordsStandard program records are tailoredto meet the precise need forinformation required by the providerand its funders, and are not excessivelyintrusivewithoutprogrammaticnecessity. The provider has a clearrationale for all information which ismaintained in resident records.Programs have record keeping systemsthat are secure against inappropriateaccess.The provider has a policy for clients toreview their records, upon requestwithin a reasonable amount of time.Section 3 – Page 4

Case Management Intake and Assessment FormThis form is to be filled out with information gathered from both the client and collateral contacts. Some questions touch upon sensitive topicswhich the client may not be ready to discuss during a first meeting (custody issues, domestic violence, legal issues, etc.). If this occurs, considerwaiting until a later meeting to ask these questions; when the client may feel more comfortable.General InformationResident Name: Preferred 1st Name:Phone: Phone where message may be left:Primary Address:City State ZipDate of Birth: / /Place of Birth (city/state/country): Gender:Racial or Ethnic Background: Religion (optional):Social Security Number: - -Date of Admission to Housing Program: / /Emergency Contacts:#1: Name:Is this person aware of client’s HIV/AIDS status?#2: Name:Is this person aware of client’s HIV/AIDS status?Primary Care Physician Name:Relationship: Phone:yesNoDon’t knowRelationship: Phone:yesNoDon’t knowPhone Number:Address:Hospital Affiliation:Additional Health Care Providers:Name:Specialty:Phone Number:Name:Specialty:Phone Number:Section 3 – Page 5

Source of Referral to HIV/AIDS HousingSelfHousing AdvocateCase ManagerDetox ProgramSubstance Abuse Treatment FacilityHomeless Services/ShelterAdult/Juvenile Detention FacilityCounseling and Testing SitePrevention Education ProgramMental Health ProgramSTD ClinicHealth CenterEmergency RoomHospitalStreet Outreach WorkerOtherMedical InformationDate of HIV diagnosis: / /Does client have AIDS diagnosis?yesnoIf yes, date of AIDS diagnosis: / /Verification: Physician, Date: / /What were the results of the client’s most recent CD4 count? %Date: / /Using table below, list current and recent HIV-related illnesses / symptoms / opportunistic infections.Illness / Infection / SymptomsPresent?Any Hospitalizations? List details:Section 3 – Page 6

PPD:TB Screening:Hepatitis Screening:Alternative Therapies:Date: / /Results:A:Date: / /Results:Vaccinated?yesnoB:Date: / /Results:Vaccinated?yesnoC:Date: / /Results:yesnoIf yes, please list:Current medications:NameFrequencyReasonIs client allergic to any medications?yesnoIf yes, please describe:Section 3 – Page 7

Family InformationDoes client have a partner or spouse?yesnoDoes client have any children in family?yesnoIf yes, does client live with partner or spouse?yesnoIf yes, fill in the chart below for all children. (When more space is needed, please use blank paper).NAMEAGEGENDER(Circle One)RELATIONSHIPTO CHILDCURRENT WHEREABOUTSMale / FemaleMale / FemaleMale / FemaleMale / FemaleMale / FemaleMale / FemaleIf client is separated from child, is there a plan for or interest in reunification with the child?yesnoIf yes, describe:Is a child protective services agency currently providing any assistance to the family?yesnoIf yes, describe:Has the client ever experienced ANY personal violence; being hit or abused physically, sexually, emotionally, or verbally?yesnoIf yes, please describe. Please include whether the client has an Order of Protection and the current whereabouts of the abuser).Does the client have any other needs related to children, partners, or family members?yesno If yes, describe:Section 3 – Page 8

Practical Supports and AssistanceRemembering appointmentsChildcareDoing laundryTransportation to appointmentsManaging finances / budgetingCooking / food preparationMaking appointmentsPersonal care (bathing, dressing etc.)NutritionRemembering medicationsCleaning / housekeepingShopping (Grocery)Communicating needs to othersSupervision for safetyShopping (Pharmacy)Social Support SystemsIdentify social support system, both informal (family, friends, caregivers) and other (other agencies, support groups, spirituality):NameRelationship / AgencyAware of HIV / AIDS Status?YesNoDon’t knowYesNoDon’t knowYesNoDon’t knowYesNoDon’t knowComments on social support systems:Employment / Job Training / EducationClientWorks full-timeWorks part-timeWorks in “temp” jobsCurrently unemployedIf employed, indicate current occupation:Employer name and address:Does HIV affect your ability to do your job in any way?yesnoIf yes, how?Contact name: Phone: ( )Length of Employment:If not currently employed, indicate most recent occupation:Does the client need any assistance with:Otherworkforce trainingfinding employmenteducation(explain)Section 3 – Page 9

Household IncomeList all persons in the household with any form of income including live-in boyfriends/ girlfriends. List children live with client.Names of individuals who willlive with the clientRelationship toclientClientSelfAgeSource(S) of income *(Wages, SSI, AFDC,etc.)MonthlyIncome*TotalHousehold Income:AnnualIncome* * Leave blank for official Personal Care Attendant for whom medical documentation can be supplied evidencing this role.Legal and AdvocacyDoes the client need any assistance with:willguardianshipimmigrationpower of attorneyhealth care proxyprior evictionscredit problemsotherProbation:YesNoProbation officer: Phone: ( )Parole:YesNoParole officer:Pending court case:YesNoPhone: ( )If yes, what issue: Date due in court: / /Any other agency involvement?YesNo If yes, which?SpiritualIs the client connected to any spiritual or religious support?YesNoIf yes, please explain:Does client express need for connection with spiritual or religious support?YesNoIf yes, please explain:Section 3 – Page 10

Recreational / Social Community erson completing this form (Print):Date: / /Signature:Title:Client Signature: Date: / /Section 3 – Page 11

Addictions Support Assessment FormCan be conducted in conjunction with intake or as a separate assessmentInterviewer Name:Dates of Assessment:Location:It is important to begin your drug and alcohol assessment with a description of the agency’s policy on this issue. You should indicate thatdrug and alcohol history does not disqualify a person for the program. To the contrary, the best way for the applicant to qualify is byproviding as thorough a history as possible such that the agency can make an accurate assessment of the individual’s needs.Begin this interview with a general discussion about the climate of drug and alcohol use in which person was raised and has been living.Family history of drug / alcohol motherChildrenOther Relative(s)Other commentsSpouse / partner historyActive UserCleanNever usedDealerOther comments:Section 3 – Page 12

Indicate again to applicant that acceptance into the program is not predicated on their drug and alcohol history. The questions aredesigned

Section 3 Assessing Clients’ Needs FORMS IN THIS SECTION Intake-Assessment Packet o Case Management Intake- Assessment Form o Addictions Support Assessment o Mental Health Assessment Form (for mental health professionals) o Medical Diagnosis Form o HIV Benefits Screening Form (MA specific) RELEVANT STANDARDS OF CARE