[agency name]

Couples HIV Testing (CHT) - VerbalConsent Form

You are giving consent to ______(agency name) to provide Couples HIV Testing, which is joint HIV testing counselling.

  • You should understand that as part of your testing session HIV risk factors will be reviewed and will result in discussion about HIV risk reduction strategies.
  • You should understand that each of you will be encouraged to participate equally in the discussion, and you agree to listen carefully and respond to each other.
  • You should understand that information about past and current HIV risk activities may be discussed and you understand the importance of a shared confidentiality about these matters.
  • You should understand that you will be tested together and be made aware of your partner(s)’s HIV status. You understand that decisions about sharing today’s test results with other people will be made together.
  • You will treat each other with respect and dignity, and will be as open and honest as possible while receiving couples HIV testing counselling.
  • You agree to provide understanding and support to each other as we discuss HIV as it pertains to your shared lives.
  • You should understand that the counsellor may, at any point in time during your visit or during the CHT session, elect to separate youinto different rooms to deliver the testing and provide your results individually.

In providing your consent for your testing counselling session today, you:

Agree to discuss your HIV risk issues and concerns together

Agree to receive your HIV test results together

NOTE TO STAFF PERSON:

PLEASE REVIEW THE CHT STAFF FLOW SHEET FOR THE ADDITIONALCONSENT REQUIREMENTS CHECKLIST AND THE CHT PROTOCOL STEP 1 REQUIREMENTS.

(Optional)

Date: ______HIV Testing Provider (print name): ______

Time Started: ______Time Finished: ______

(vJune 2015)