Staff-facing Concierge Enrollment Form - CHI EveryYou Health Form

Customized education on PrEP treatment – developed to support those considering treatment and patients already on PrEP.

"*" indicates required fields

Answer the questions below so that we can send you the information that best meets your needs.

Name*

First Last

MRN*

Date of Birth:*

MM slash DD slash YYYY

Mobile number:*

Insurance:*

Uninsured

Medicaid

Managed Medicaid

Medicaid and Medicare

Medicare

Medicare & private insurance

Private insurance (including ACA)

How long have you been taking PrEP?*

I am just starting

Less than one year

1-3 years

More than 3 years

Which PrEP medication are you currently taking?*

Descovy

Truvada

Apretude

Other

You chose "Other", please specify*

Note: The following information is used to send the patient lifestyle-specific messaging. If you are not comfortable asking the patient for the following information, skip the section by selection “next” at the end.

“Great! Now let’s learn a little bit more about you. EveryYou Concierge is designed to provide whole-person care personalized to our patient’s lifestyle and needs. The following questions will help us provide you with the right support most relevant to your treatment, needs and preferences. Your information is kept completely private.”

Sexual Orientation

Do you think of yourself as

Straight or heterosexual

Lesbian or gay

Bisexual

Queer, pansexual, and/or questioning

Something else

Don’t know

Decline to answer

Please specify:

Gender Identity

What sex was originally listed on your birth certificate?

Male

Female

Decline to answer

Do you think of yourself as:

Male

Female

Transgender man/trans man

Transgender woman/trans woman

Neither exclusively male nor female (Genderqueer/gender nonconforming)

Additional gender category (or other)

Decline to answer

Please specify:

Living Situation

Check the item below that best describes your lived environment.

This is so we can suggest plan of care options that will meet your privacy preferences and environmental needs:

I live in my own house or apartment by myself

I live in my own house or apartment with family

I live in my own house or apartment with friends

I live in the house or apartment of a family member

I live in the house or apartment of a friend or someone who is not family

I live in a homeless shelter

I am currently homeless

Almost done!

Terms and Conditions (Read the following terms and conditions to the patient and check off once they consent. Note: Patients will also receive a copy of the terms and conditions once enrollment is complete.)*

I agree to receive periodic text related to this program, PrEP treatment, and services offered by EveryYou Health. I understand that text is not considered a secure technology and that the messages I receive may indicate the nature of my condition. However, beyond the general nature of my condition, this program does not send protected health information (PHI) via text. I understand that the program uses text messages from my text plan and there are no additional charges.

I have read and agreed to the terms and conditions of this program