EC-314 - Cenpatico HIV Early Intervention
Monthly Report for County/ies ___
Instructions
Please complete this monthly report 15 days after the end of each month to the Cenpatico HIV coordinator. In addition, requests for monthly payments for the providers will be generated after this report is received.
Name of provider: Year _____ Month Reported ______
Please list the HIV related training received by HIV program staff in the last month:
(indicate trainings your staff attended in the past month)
Please indicate summary of intervention: (provide a short summary of monthly activities)
List of locations for delivery of intervention, include date and number of people:
Please fill all applicable boxes below:
Section A: Persons Served
Services delivered at a substance abuse treatment site.(Services to individuals who are engaged in substance abuse treatment) / Community outreach
(Services delivered to persons with substance abuse disorders who are not currently engaged in substance abuse treatment or drop in center)
Total number of persons served (unduplicated):
RBHA enrolled substance abuse treatment recipients
RBHA enrolled behavioral health recipient with a serious mental illness
Persons receiving treatment engagement services [1]
Injection drug users
Pregnant women
Women with children
Persons in a criminal justice setting
Persons in a homeless services setting
Persons in a domestic violence shelter
Mobil setting (please describe: )
Other persons (please describe: )
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Section B: Services Delivered:
Services / Services delivered at a substance abuse treatment site(Services to individuals who are engaged in substance abuse treatment) / Community outreach
(Services delivered to persons at high risk for HIV, but not currently engaged in substance abuse treatment)
Total number of sites in which HIV services were delivered
Number of 15 minute units of HIV education and health promotion services provided
*you can provide the hours spent per month and divide by 4 to find the 15 minute units
Number of HIV Risk Assessments completed
Number of pre-test counseling sessions provided
Number of HIV tests administered
Total number of seropositive test results
Number of post-test counseling sessions provided
Number of 15 minute units of HIV case management services delivered
Number of 15 minute units of HIV case management services delivered to HIV positive persons.
Number of 15 minute units of peer support provided
Number of 15 minute units of family support provided
Number of 15 minute units of client transportation provided
Number of 15 minute units of interpretation services provided
Number of 15 minute units of other support services provided [2] (please describe)
Number of referrals to substance abuse treatment
Number of 15 minute units of treatment engagement services (please describe in the space below this table)
Section C: Demographics (unduplicated)
Persons who received services delivered at a substance abuse treatment site.
Persons who received services via community outreach
Ethnicity
Hispanic/Latino / Not Hispanic Latino / Unknown
Persons who received services delivered at a substance abuse treatment site.
Persons who received services via community outreach
Gender
Male / Female / Transgender
Persons who received services delivered at a substance abuse treatment site.
Persons who received services via community outreach
Age
Under 5 / 5-12 / 13 -19 / 20 -29 / 30-39 / 40-49 / 50-59 / 60 and older
Persons who received services delivered at a substance abuse treatment site.
Persons who received services via community outreach
Additional information:
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[1] Treatment Engagement Services are the services that attract the targeted population (homeless or near homeless substance abusers at risk for HIV) i.e. breakfast, showers, and lunches.
[2] Support Services: includes transportation (bus tickets), haircuts, healthcare for the homeless etc.