The Positive Life Workshop Screening Assessment Form

1. Contact Information *This question is required.

First Name

Last Name

Street Address

Apt/Suite/Office

City

State

Zip

Email Address

Phone Number

3. Are you having issues with managing your health care and/or treatment adherence? *This question is required.

4. When were you diagnosed with HIV? (MM/YYYY) *This question is required.

5. Are you currently in medical care? *This question is required.

6. When were your last 2 medical appointments? *This question is required.

Date (MM/YYYY) *This question is required.

Space Cell	Appointment 1	Appointment 2
Date	Date: Appointment 1	Date: Appointment 2

Attended *This question is required.

Space Cell	Appointment 1	Appointment 2
Attended	Attended: Appointment 1	Attended: Appointment 2

7. Why are you interested in attending The Positive Life Workshop? *This question is required.

8. Which cycle of The Positive Life Workshop are you interested in attending? *This question is required. This question requires a valid number format.