This support manual describes the features of the CLUB 1509 HIV Navigation Program and provides sample demonstrations of the assessment tools, and program standards. It was written for the navigation teams who would like a point of reference for all CLUB 1509 service tools, client flow chart, and program standards. This support manual is organized by task. It begins with the philosophy of care for all CLUB 1509 clients and progresses through more complex tasks such as client home visits, and biopsychosocial assessments. This supportive manual is not intended to replace your formal social work experience or your agency’s administrative protocol. This manual aims to introduce you to and support your journey in the CLUB 1509 program.

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Philadelphia Department of Public Health,
AIDS Activities Coordinating Office
February 2017
CLUB1509 Navigation Support Manual

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Dear CLUB 1509 Navigation Team:
This support manual describes the features of the CLUB 1509 HIV Navigation Program and provides sample
demonstrations of the assessment tools, and program standards. It was written for the navigation teams who would
like a point of reference for all CLUB 1509 service tools, client flow chart, and program standards.
This support manual is organized by task. It begins with the philosophy of care for all CLUB 1509 clients and
progresses through more complex tasks such as client home visits, and biopsychosocial assessments. This
supportive manual is not intended to replace your formal social work experience or your agency’s administrative
protocol. This manual aims to introduce you to and support your journey in the CLUB 1509 program.
The CLUB 1509 topics and materials listed in the manual were chosen to meet the program needs of the
Navigation team as identified by the AIDS Activities Coordinating Office (AACO). All resources in this manual
had to meet selection criteria developed with guidance from our evaluation staff to ensure accuracy and
appropriateness. Almost all of the resources and tools listed are available in the CLUB 1509 Google drive.
Any questions about this support manual can be directed to:
Antar Bush, Health Educator Coordinator
Antar.bush@phila.gov
or
Philadelphia Department of Health
AIDS Activities Coordinating Office of Philadelphia
PO Box Office #58909
Philadelphia PA 19102

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CONTENTS
Philosophy of Care for ........................................................................................................4
Who is Served .....................................................................................................................5
Services Overview ..............................................................................................................5
Intended Outcomes for Navigation Services ..................................................................5-6
Enrollment Process .........................................................................................................6-7
Service Flow Chart ..............................................................................................................8
Service Continuum...............................................................................................................9
Team Member’s Role and Functions ............................................................................9-10
HIV Positive Handoff to Ryan White ..............................................................................10
Referral & Linkages.....................................................................................................11-12
Service Monitoring .....................................................................................................12-14
Home Visits..................................................................................................................14-15
Transition Planning............................................................................................................15
Client Safety Issues......................................................................................................15-17
Condom Usage………………………………………………………………...………17-19
Supervision ..................................................................................................................19-21
CLUB 1509 Forms.......................................................................................................21-22
Documentation Best Practices ..........................................................................................21
Documentation Usage .................................................................................................23-43
Definitions ...................................................................................................................44-45
Program Locations ............................................................................................................46

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Philosophy of Care for CLUB 1509 (Community Linkages Upholding Healthy Behavior)
The CLUB 1509 program combines client brokerage and therapeutic models of social work in a team approach. It
provides short-term “wrap-around” services, and intensive follow-up to mitigate the BioPsychoSocial and
structural barriers to HIV prevention faced by Men who have Sex with Men (MSM) and Transgender people of
Color. CLUB 1509 navigation teams support clients to develop or enhance self-sufficiency skills, utilize care, and
access prevention services in the Philadelphia area. Using a holistic approach, CLUB 1509 supports clients to
combat social determinants such as food insecurity, housing, education deficiencies, and health care needs.
CLUB1509 is designed to provide the following:
 Aid the client in accessing health care and other medical services.
 Support clients in learning new skills which will increase coping and healthy behaviors.
 Support clients with identifying and obtaining supportive social services.

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WHO IS SERVED
CLUB 1509 is designed to provide intensive navigation services targeted to HIV negative, and newly diagnosed
HIV positive MSM and Transgender persons of Color. However, all CLUB 1509 services are available to HIV
negative and newly diagnosed HIV positive persons regardless of age, gender, race, ethnicity, sexual orientation,
gender identity, or socio-economic status.
It is expected that agencies funded to provide navigation services will be able to demonstrate that they are
targeting services to Black and Latino MSM and Transgender persons, while having appropriate screening
mechanisms to ensure that those persons outside of the target demographics, but who present high needs for
navigation, are able to access services.
SERVICES OVERVIEW
Client needs will vary and may include but are not limited to: PrEP/nPEP, PrEP adherence, HIV medication,
behavioral health, insurance, education, housing, and employment.
CLUB 1509 providers’ activities for HIV negative clients are as follows:
 HIV testing services that use 4th generation technology
 Assessment for PrEP and PEP
 Provision of PrEP and PEP
 Adherence interventions for PrEP and PEP
 STD screening and treatment
 Partner Services referrals for patients with STDs
 Behavioral risk reduction interventions
 Screening for behavioral health and social services needs
 Linkage to behavioral health and social services needs
 Accessing HIV prevention, behavioral health and social services needs
 Enrollment in a health plan
 Short term emergency mental health (MH) services while linking to ongoing MH care
CLUB 1509 providers’ activities for HIV positive clients are as follows:
• Immediate linkage to care, ARV treatment and PS for acutely infected individuals
• Expedient linkage to care, ARV treatment and PS for individuals with established infection
• Linkage to retention interventions (MCM)
• Re-engagement interventions (data-to-care)
CLUB 1509 works in collaboration with supportive social service agencies to meet the client’s health goals. In
addition, the program teaches the client how to effectively utilize their own strengths and community resources to
ensure better health outcomes. It is expected that navigations services discharge clients at 6 months with no need
for additional services. There are some instances in which more intensive services are warranted to stabilize a
client. A client may be retained for an additional six months if deemed appropriate after re-assessment with
permission from the navigation supervisor.
INTENDEDOUTCOMES FOR NAVIGATORS:
The intended outcomes of CLUB 1509 are to:

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A. Reduce HIV risk for high risk negative persons through a holistic approach to HIV prevention and care
that will address structural HIV risks.
B. Provide expedited linkage to medical care and MCM for persons newly diagnosed.
Services are intended to enable clients to resolve social needs that contribute to the risk of acquiring and
transmitting HIV. Specific service outcomes towards this goal include:
1. Increased number of MSM and Transgender individuals of Color with a risk event who presented within
72 hours of the event, and were linked to a Post Exposure Prophylaxis (PEP) provider for clinical
evaluation on the same day they presented.
2. Increased number of MSM and Transgender individuals of Color with a negative HIV test and at
substantial risk for HIV who were linked to a Pre Exposure Prophylaxis (PrEP) provider for clinical
evaluation.
3. Increased percentage of MSM and Transgender individuals of Color diagnosed with acute HIV infection
who were linked to medical care within 7 days of diagnosis (immediate linkage).
4. Increased percentage of MSM and Transgender individuals of Color diagnosed with an acute HIV
infection that were initiated on Anti-Retroviral Treatment (ART) within 14 days of diagnosis (immediate
treatment).
5. Increased percentage of MSM and Transgender individuals of Color diagnosed with an established HIV
infection that were linked to medical care within 30 days of diagnosis (expedient linkage).
6. Increased percentage of MSM and Transgender individuals of Color living with HIV who received
retention interventions and who subsequently had at least 1 medical visit in each 6 month period of a 12
month follow up.
7. Increased percentage of MSM and Transgender individuals of Color diagnosed with HIV who were
retained in HIV medical care, with a least 1 HIV medical care visit in each 6 month period of a twenty-
four month measurement period, with a minimum of sixty days between visits.
8. Increased percentage of MSM and Transgender individuals of Color living with HIV identified as out of
care who attended at least 1 medical visit within 90 days of receiving outreach from program staff.
9. Increased percentage of MSM and Transgender individuals of Color who received timely partner service
interviews after receiving a positive HIV test result.
10. Increased percentage of MSM and Transgender individuals of Color at risk for or living with HIV who
received risk reduction interventions.
11. Increased percentage of MSM and Transgender individuals of Color at risk for HIV acquisition or living
with HIV who were screened for behavioral health and social services' needs (i.e., behavioral health
services, housing programs, job training and/or employment services).
12. Increased percentage of MSM and Transgender individuals of Color at risk for HIV acquisition or living
with HIV who needed any specified behavioral and social service (i.e., behavioral health services, housing
programs, job training, and /or employment services) and were linked to the service.
13. Increased percentage of MSM and Transgender individuals of Color at risk for HIV acquisition or living
with HIV who needed health insurance and were linked to the service.
ENROLLMENT:
HIV testing serves as the gateway for all navigation services. Clients who present for HIV testing are assessed for
eligibility and appropriateness for CLUB 1509 services. Those who are appropriate and test HIV negative are

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referred to navigation for assessment and referral to support services, including PrEP. Those who test positive are
referred to navigation for immediate or expedited linkage to medical care.
Clients who are high risk HIV negatives as documented through the CLUB 1509 eligibility tool or newly HIV
positives will be referred to CLUB 1509 navigation services by the provider’s existing HIV testing program. If a
CLUB 1509 navigation team member is available on site the client will have a warm handoff directly to
navigation. If a CLUB 1509 navigation team member is unavailable on-site, a member of the navigation team
must contact the client within one business day of the HIV test.
Due to the team based nature of CLUB 1509, it is vital that the navigation team maintains constant
communication with the provider’s testing and linkage staff. It is the responsibility of the navigation team to
determine where the client is in the CLUB 1509 enrollment process, and what immediate referrals and linkages
were made by the testing and linkage staff prior to CLUB 1509 intake.
Navigators will assess high risk HIV negative persons for suitability for PrEP/nPEP, and make social services
referrals as necessary. For clients that are newly infected with acute or established HIV, Navigators will make
immediate linkage to Ryan White medical care and medical case management, and Antiretroviral (ARV)
treatment.

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CLUB 1509 Services Flow Chart

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SERVICE CONTINUUM
CLUB 1509 Navigation services provide professional services to the client. The direct intervention of navigation
services is an important component of service delivery. The navigation team will develop a therapeutic
relationship with the client to promote healthy behaviors that reduce the client’s risk for contracting HIV or link to
HIV medical care if newly positive.
The CLUB 1509 team asserts interventions in three phases: Engagement, Development, and Disengagement.
 Engagement phase: focuses on assessments, referrals, and service linkage.
 Development phase: focuses on maintaining clients in services and developing client self-sufficiency
skills to continue in services post-navigation program.
 Disengagement phase: focuses on assessment of client ability to maintain self engagement in linked
services in the absence of navigation support, and re-assessment for any other needed supportive services.
Several sessions in the final four weeks of the intervention will be devoted to discussing the conclusion of
services. This phase of the program will need to be adjusted depending on the client and the execution of
services.
Team Member Role and Duties
Navigator:
 Serves as the team lead, providing oversight and direction to the Assistant Prevention Navigator
 Reviews eligibility assessment to ensure appropriateness for services
 Completes a detailed biopsychosocial assessments (in office and/or at home) at intake
 Utilizes a detailed understanding of the social service referral system in Philadelphia to refer clients to
needed medical and behavioral health services
 Provides short term mental health interventions and other therapeutic support
 Continuing assessment of needs and building capacity for self sufficiency
 Writes client action plans
 Conducts case conferencing
 Documents services through progress notes
 Employs understanding of issues of boundaries and transference
 Demonstrates competency in all facets of client-centered care including utilizing the MINI
International Neuropsychiatric Interview, PrEP adherence counseling, risk reduction planning and
referrals
 Provides risk reduction interventions in accordance with the standards established by the Center of
Disease Control
 Submit weekly/monthly statistical reports and enter CareWare data as required
 Educates and builds relationships with other providers of services
 Remains informed about PrEP and nPEP guidelines and local resources
 Participate in all training requirements
 Performs other duties assigned based upon evolving needs of clients and the overall program
Navigator Assistant:

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 Follow up on referrals noted on the Action Plan.
 As needed, accompany clients to their medical and other behavioral health and social service
appointments.
 Assist clients in problem solving around barriers to referrals
 Assist clients to integrate themselves within systems of care
 Provide field documentation of activities
 Home visitation
 Consult with the Navigator regarding identified needs
 Provide “professionalized” support
 Contact clients on at least a weekly basis
 Assist the Prevention Navigator to assess clients’ linkages to health care, behavioral health and social
services
 Maintain a weekly activity schedule
 Maintain a team structure and a flexible schedule that will accommodate serving as a back-up to the
Prevention Navigator.
 Participate in all training requirements
 Performs other duties assigned based upon evolving needs of clients and the overall program
HIV Testers and Linkage Specialist:
 Assess client eligibility for CLUB 1509 Navigation Services using the Eligibility Form at the point of
care.
 Encourage clients to participate in the CLUB 1509 navigation program.
 Refer and link all eligible clients that accept CLUB 1509 Navigation Services directly to the navigation
team.
 Refer to page 8 Eligibility Process
Handoff to Ryan White Medical Case Management (MCM):
Warm handoffs between the navigation team and medical case managers are a vital part of the CLUB 1509
program. Communication breakdowns can lead to a client being lost to care. CLUB 1509 requires the following
when referring a client to Medical Case Management (MCM) Services:
 Client Overview to MCM. Navigation team should give a brief narrative of the client by providing copies
of all current and completed documentation.
 Safety Concerns: Note the client’s environment and the potential risks.
 Plan of Care: Share referrals and linkages already made, and action plans.
 Questioning: Navigation team should provide the MCM the opportunity for questions to ensure
communication is clear.
The process of MCM Hand Off
 Client tests HIV positive
 Client is assessed for appropriateness and referred for navigation
 Navigator links to medical care, assures attendance of one primary care visit, and prescription of ARV
therapy

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 Navigators at agencies with MCM services make an internal agency referral into Medical Case
Management (MCM)
 Navigators must call The Health Information Helpline at (215-985-2437) to notify staff that client is being
linked to their agency for MCM
 Those clients who wish MCM at another agency should be given assistance to contact the helpline (215-
985-2437).
REFFERALAND LINKAGE
The Navigation team links and maintains the client in the services included in the CLUB 1509 Action Plan.
Navigator Role
The Navigator is responsible for creating referrals based upon the intake and follow up assessments. Referrals
should be based upon assessment of client need and to providers which are most appropriate for the client based
upon culture, language, geography, and other determinants of vital importance to clients. Navigators should
develop a broad range of referral sources, considering that client needs may not be best addressed at the
Navigators preferred places of referral, including the Navigator’s agency. Navigators refer and link clients to
supportive services that meet the individual’s needs rather than fit the client into an existing service. The client
participates as a full partner in all stages of the decision-making and the action planning process. The Navigator
should document all referrals and provide written communication of referral to the Navigator Assistant. The
Navigator should assess for continued appropriateness of the referral at each meeting with the client as well as any
subsequent referral needs. Navigators educate clients with how to apply for and maintain benefits. Navigators
also should communicate with referral sites to address barriers as they arise, including problems which may cause
termination of services for the client at the referral site. Always refer to the Navigator’s role as much possible
when you inquiries about tasks.
Navigator Assistant Role
The Navigator Assistant is responsible for assessing any barriers the client may have to accessing the referrals.
Navigators then must assist the client in being linked to the referral source. As often as possible with permission
from the client, the Navigator Assistant accompanies the client to the first contact between service providers and
the client. Thereafter, the Navigator Assistant should contact the referral source to ensure that the client is
receiving the services requested and that those services are appropriate. The Navigator Assistant will assist in
resolving problems which may arise at the referral site that may cause termination of services for the client.
Navigator Assistants must also continually assess client engagement in services, to ensure that the services are
meeting the underlying goal of the referral, and be prepared to provide ongoing support in maintaining a client in
services.
The CLUB 1509 Collaborative
In support of the referral and linkage process, the CLUB 1509 Collaborative was established. The CLUB 1509
Collaborative is comprised of a variety of agencies throughout Philadelphia that provide services related to
education, employment, housing, food, legal, health insurance, behavioral health, and financial services.
Relationships have been established with these partners to ensure that the program receives information regarding
events, services and other helpful information to support in the linkage process. Most CLUB 1509 Collaborative
organizations will offer expedited entry into services for CLUB 1509 participants. Navigation teams should
consult the most recent CLUB 1509 Collaborative list to get information on all agencies participating in the
project.

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For any issues or challenges that may arise with the CLUB 1509 Collaborative sites please contact J. Maurice
Pearsall, Program Coordinator at maurice.pearsall@phila.gov.
SERVICE MONITORINGANDREPORTING:
Team meetings are conducted with the client, Navigator, Navigator’s assistant, and supervisor, at the mid-point,
and discharge conferences, or when necessary to assist with the process of the client’s self-sufficiency. These
meetings are used to identify the natural supports such as neighbors, extended family members, friends and
selected community members of the client to support in the process of meeting service plan goals.
HOME VISITS
Home visit with the Navigators or Navigator assistants are the secondary venue for the provision of direct
services and supports the client. These contacts provide the opportunity to identify the assets and resources
available to the client that may not be evident without engaging the client in their natural environment. Navigators
spend a minimum of 30 minutes in the client’s home or “home” community at the decision of the client.
Navigation teams will document any safety concerns they may see in the home in the assessment portion of the
progress note.
Home visits should be at the convenience of the client and take into consideration the client’s schedule.
During the home visit, navigation teams engage the client to work towards addressing the goals and objectives
that have been agreed upon in the Navigation Action Plan. Navigation teams introduce services available to the
client including but are not limited to: individual counseling, education skills, PrEP, and behavioral health
services. For clients referred to navigation services for PrEP adherence or environmental concerns, Navigators
should support the client with routine check-ins for establishing a PrEP adherence schedule.
Tips for an effective Home Visit1
 Every home visit should have a clear purpose. Navigators and Navigator Assistants should be able to
identify the purpose and be prepared to articulate that to the client.
 Preparing for the visit includes planning how to accomplish the purpose, including who needs to be there,
topics to discuss, and issues that may arise.
 Preparation also includes planning for worker safety, making decisions whether someone should
accompany the worker, or deciding if the visit should occur elsewhere.
 Navigators and Navigator Assistants should conclude visits with summary statements and plans for next
steps.
Before the Visit2
 Set up appointment by letter or phone.
 Prepare paperwork packet
 Arrange for an interpreter, if needed.
 Have forms semi-completed before you arrive at the appointment.
1 Adapted from Effective Use of Home visits: A Supervisor’s Companion Guide.Developed by the Institute for Human Services for the
Ohio Child Welfare Training Program. August 2011
2 Adapted from The Home Visit Checklist.The California Department of Social Services. Retrieved from
www.cdss.ca.gov/agedblinddisabled/res/SWTA/IHSS101_PartII.pdf.

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 Familiarize yourself with case.
 Review narrative notes from last home visit and any notes documenting phone calls to identify any
potential issues that will need to be addressed during the home visit.
 Make notes to take with you or copy information, if necessary.
 Pay special attention to safety (i.e., dogs, illegal activity expected, behavioral health issues).
 Make any contacts that you feel will help you do a thorough assessment or answer questions that you may
have.
 If indicated, get input or discuss concerns with supervisor.
During the Visit:
 On entry into the home, be sure to inquire as to who is currently present in the home.
 Ask for permission to be seated. This gives the client control early on and helps with rapport building.
 Explain the purpose of the visit.
 Observe client's abilities. This should begin with observing how the client greets you and continue until
the interview is concluded.
 Observe environmental safety issues (i.e., throw rugs, lack of handrails, etc.).
 View all rooms in the home utilized by the client (if reassessing, check that assessed chores are being
completed).
 Suggest/make referrals as needed.
 Assess the need to make referrals.
Safety
General Tips:
 Pay attention to intuitive feelings.
 Be alert to your surroundings.
 Anticipate potential problems.
 Keep a list of your credit card numbers in a safe place.
 Carry only enough money to get through the day.
 Maintain your car. Make sure you have enough gas.
 Carry a cell phone.
 Obtain any history of clients to be visited (i.e., behavioral health, chemical abuse, history of violence,
criminal activity, non-compliance with medication, violent or criminal family members, etc.)
Appearance is Everything:
 Dress practically.
 Wear clothing that allows you to move freely and wear comfortable walking shoes.
 Avoid wearing expensive jewelry or accessories.
 Walk with confidence and purpose - head up, eyes forward.
 Keep your purse or wallet out of sight or lock them in the trunk.
 Keep car keys handy at all times.
Protect Your Health:
 Learn about any situations that might jeopardize your health.
 Use universal health precautions.
 Carry sanitary wipes or antibacterial lotion.
Know Where You Are Going:
 Plan your route and carry maps.

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 Learn about the neighborhood you will be visiting.
 Go with assistance if you're concerned
 Let people know where you are going: Give location, name of consumer, license plate of your vehicle, and
time you are expected to leave location with a supervisor or co-worker.
 Don't carry any weapons. (In case of emergency, pens, clipboards, keys, etc. could be used for protection.)
 Have supervisor or co-worker make a safety check phone call at a predetermined time.
Before You Get Out of the Car:
 Check out the neighborhood as you drive in.
 Drive around the block, try and see what is happening behind the house.
 If you don't feel safe, do not get out of the car. Leave.
 Park in a visible area as close to the consumer's residence as possible.
 Think about an escape route.
Getting to the Door:
 Lock your car.
 Be prepared to drop items you are carrying.
 Do not stop to speak to strangers.
 If you must respond, keep walking.
 Before entering a fenced yard, make noise to see if any animals are present.
 Do not enter the home if an animal threatens your safety (ask the consumer to secure the animal).
 After knocking, stand away from the door and to one side if possible - hinge side is best for providing
protection.
 In an elevator, stand near the control panel.
 Leave the area if your instincts tell you to.
Entering the Consumer's Home:
 Fo11ow clients up the stairs. Do not let them behind you.
 Observe the inside of the consumer's home before entering.
 Once in the home, look around for signs of dog. Ask if the dog is safe/friendly if it is locked up.
 Don't enter the home if you suspect that the client is under the influence
 Try to make eye contact with anyone present.
 Sit near an exit door and be prepared to leave at any sign of danger.
 Do not allow anyone between you and the door.
After the Visit:
 Have your keys in your hand when returning to your car.
 Check the inside of your car before getting in.
 Document any unusual or unsafe conditions.
 Discuss concerns with your supervisor.
 Develop strategies to address concerns for future visits.
 Cleanse your hands immediately following every visit
TRANSITION PLANNING
Meetings are conducted with the client, navigation team, and supervisor at 3 months of service (referred to as the
Midpoint Conference Meeting) and the 6 months of service (referred to as the Discharge/transition Conference
Meeting) to review the service plan and develop aftercare and discharge plans. These meetings are held to discuss

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the progress of the client, and whether or not additional community based services are needed to support the client
until the client has become self sufficient.
CLIENT SAFETY ISSUES
Navigation services, on occasion, identify clients that may be in need of more intensive services because a safety
threat has been identified with the client. A safety threat is defined as the condition or actions with a client that
represents the likeness of imminent serious harm. There are two types of safety threats:
 Present Danger- an immediate, significant, and clearly observable client condition occurring to the client
in the present.
 Impending Danger refers to threatening conditions that are not immediately obvious or currently active
but are out of control and likely to cause serious harm to the client in the near future.
For these periodic occurrences, a meeting is conducted with supervisor in order to determine the appropriate next
steps for the client.
Navigation team need to documents identified threats to the client, and discuss with the Navigator assistant and
Supervisor. A primary function of the Supervisor is to ensure the quality of work related to safety decisions
making. As mandated reporters, if a Navigator or Navigator’s assistant suspects abuse or neglect to a minor a
hotline report must be made immediately by calling the state Child Abuse Hotline 1-800-932-0313. In these rare
cases the Navigation team will notify the Supervisor immediately of the incident. The Supervisor will then notify
the provider’s Executive Director no later than 24 hours after call has been made to the hotline and follow-up with
an email notification to CLUB 1509 Coordinator.
It is imperative for navigation teams to become familiar with their agencies own safety protocols to ensure
optimal crisis management.
CONDOM USAGE
It is imperative for CLUB 1509 navigation teams to provide to their clients information and skills building
training in risk reductions methods to reduce the risk of transmitting or contracting HIV. Condoms and other latex
barriers are vital STI and HIV prevention tools. Latex condoms, used consistently and correctly, are 98-99%
effective in preventing HIV transmission. Navigation teams can use condoms and other latex barriers (e.g. dental
dams) to start the dialog around sexual health and HIV prevention with clients. These discussions should assess
readiness and willingness to incorporate condoms and latex barriers in their HIV prevention toolkit. This
discussion would include condom negotiation skills, how to properly use condoms and other latex barriers and
lubricant, and where clients can access free supplies. Navigators should support clients in the understanding
that condoms prevent HIV and STIs and should be used in combination with other HIV prevention tools,
including: nPEP, PrEP, TasP, and SAP.
Even if your clients have access to condoms and know how to use them, getting them to use them or talk to their
partner about using them can be challenging. Studies have found that MSMOC often face many barriers when it
relates to using condoms, particularly as it relates to using them consistently. Very often the act of getting to know
a sexual partner may increase the likelihood that condoms will not be used consistently. In counseling clients
about condom usage, Navigators should explore barriers (experiential or cultural) to the client using condoms as
well as client perception of condoms both physically and emotionally.

16. 16
It can be helpful if the navigation team gets the client to think about their own personal views and cultural
attitudes about sex, condoms, and relationships before trying to talk about condoms with their partner. Once the
client is clear on what is important to them and what they are willing or not willing to do with their partner
sexually, it will be easier to say these things to another person.
Navigation teams should always have both insertive (commonly called the male condom) and receptive
(commonly called the female condom) condoms available for clients who wish to use them at all sites. Condoms
should be stored at room temperature (68-77oF or 20-25oC) not in extreme heat or cold and away from moisture,
direct sunlight and direct fluorescent light. Navigation teams want to inform clients to not store condoms in a
glove compartment, trunk, wallet, back pocket or any other place where the temperature and humidity can damage
them.
In addition to latex barriers navigation teams need to talk about the role of lubricants in HIV prevention. A lack
of lubrication can lead to cause friction and cause condom breakage and damage to other rectal and vaginal tissue,
which increases a client’s risk of HIV acquisition. However, supporting clients in exploring the right kind of
personal lubricants may increase sexual pleasure while reducing STI and HIV risk. Personal lubricants are
available in three different categories: water-based (with or without glycerin), silicone-based, and oil based (baby
oil).
In order to address HIV prevention needs through condom usage in the CLUB 1509 program, a combination of
strategies are necessary. The following are evidence based techniques for navigation teams to consider when
exploring this matter with clients:
 MSM and Trans people who are regularly tested and practice condom usage will have better chance of
being link to care and treatment, should they ever acquire HIV (Parent, 2012). The CLUB 1509 program
should engage MSM and Trans people of color in navigations services when it comes to condom usage in
a appropriate ways.
 When the navigation teams engage in a combination of routine STD testing at their agencies and have
access to latex barriers this can drastically reduce a client’s risk of contracting any STD (Wall, Khosropur,
& Sullivan, 2010). It is important to remember testing alone may not be enough and can miss high-risk
individuals who are reluctant to disclose sexual behaviors or same-sex attraction.
 Being inclusive of all gender identities, sexual orientations, and language is imperative when exploring
latex barriers with clients in the CLUB 1509 program. MSM and Trans people of color need sexual health
education that promotes not only their health but their well-being (Wall, Khosropur, & Sullivan, 2010).
 CLUB 1509 navigation teams should always consider who provides the condoms and who has access to
them. It may be beneficial to include information about how to use information; teams can addresses
concerns before they can become barriers to using condoms. CLUB 1509 navigation teams can offer
clients who may have challenges accessing condoms, latex barriers, and lubrication to
the DoYouPhilly.org website for easy and quick confidential home deliveries.
 Special attention should be paid to creating a welcoming and accepting space to access all latex barriers.
CLUB 1509 navigation teams need to prioritize the barriers and challenges clients have with accessing
condoms. MSM and Trans people of color want navigations teams that can relate to their experiences and
accept them as they are (Mimiaga, Goldhammer, Belanoff, Tetu, & Mayer, 2007).
 Relevant information about local services, sexual health information, should always accompany the
condom packages and website information. MSM and Trans people of color need reliable online content

17. 17
about the CLUB 1509 program, especially those who are reluctant or unable to access free condoms in the
“gayborhood.”
 CLUB 1509 navigation teams must be sensitive to the effects of feelings and ambivalence clients may
have towards using latex barriers. Especially, since MSM and Trans people of color face stigma because of
their sexuality and/or gender expression, but also in a society with pervasive structural racism (Wilson &
Yoshikawa, 2007).
Mimiaga, M., Goldhammer,H., Belanoff, C., Tetu, A.,& Mayer, K. H. (2007).Men who have sexwith men: perceptions about sexual risk, HIVand sexually transmitted
disease testing, andprovider communication.Sexually transmitteddiseases , 34(2),113-119.
Parent, M. T. (2012).HIVTestingis so gay: The role of HIVtestingamonggender role conformityin HIVtestingMSM. Journal of COunseling Psychology , 465-470.
Wall, K., Khosropur, C., & Sullivan, P.(2010). Offeringof HIVscreeningtomenwho have sex with men by theirhealthcare providers andassociate factors. Journal of
International association of physcicians , 284-8.
Wilson, P.,& Yoshikawa, H. (2007). Improvingaccessto healthcare amongAfrican-American, Asian andPacific Islander, andLationlgbtqa populations. Thehealthof
sexual minorites , 607-637.
SUPERVISION3:
Purpose
The purpose of clinical supervision is to enhance the navigations team’s professional skills, knowledge, and
practices in order to improve outcomes for the client. Clinical supervisors’ provide navigation teams with on-
going review and direction. Furthermore, supervision may be provided in an individual and team format.
Structure
Formality and structure are very important for effective supervision. The individual conference should be a
regularly scheduled meeting at agreed time.
To maintain objectivity in supervision, it is important to negotiate a supervision contract with mutually agreeable
goals, responsibilities, timeframes, and provide regular feedback to supervisees on their progress toward these
goals. It is critical to establish a method for resolving communication concerns and other problems in the
supervision sessions so that they can be addressed, and identify and recognize feelings supervisees have about
their clients that can interfere with or limit the process of professional services. There is often a parallel process in
the supervisory relationship that reflects the process taking place between the supervisee and the client. Looking
for these parallels can be a major aid to understanding the client-supervisee relationship and the supervisory
relationship.
Confidentiality
Supervisors must ensure that all client information be kept private and confidential except where mandated by
law. Supervisees should inform clients during the initial interview that their personal information is being shared
in a supervisory relationship. Supervisors also have an obligation to protect and keep the supervisory process
3 Adapted from the National Association of Social Workers “BEST PRACTICE STANDARDS IN SOCIAL WORK SUPERVISION”
2013

18. 18
confidential and only release information as required by the regulatory board to obtain licensure or, if necessary,
for disciplinary purposes.
Leadership and Role Model
Supervisors play a key role in the professional development of their supervisees. The actions and advice of the
supervisor are keenly observed by supervisees and consequently influence much of the supervisee’s thinking and
behavior. Teaching is an important function of the supervisor, who models the behavior the supervisee will
emulate. Supervisors should create a learning environment in which supervisees learn about the internal and
external environments in which they work, as well as the environments in which their clients find themselves each
day.
Competency
Social work supervisors should be competent and participate in ongoing continuing education and certification
programs in supervision. Supervisors should be aware of growth and development in social work practice, and be
able to implement evidence-based practice into the supervisory process. Supervisors should also be aware of their
limitations and operate within the scope of their competence. When specialty practice areas are unfamiliar,
supervisors should obtain assistance or refer supervisees to an appropriate source for consultation in desired area.
Self-Care
It is crucial for supervisors to pay attention to signs of job stress and address them with their supervisees as well as
in themselves. Supervisors should provide resources to help supervisees demonstrating symptoms of job stress
and make outside referrals as necessary. Peer consultation can be helpful to supervisors and supervisees in such
cases.
Documentation
Documentation is an important legal tool that verifies that services occurred. Supervisors should assist supervisees
in learning how to properly document client services performed, regularly review their documentation, and hold
them to high standards. Each supervisory session should be documented separately by the supervisor and the
supervisee. Documentation for supervised sessions should be provided to the supervisee within a reasonable time
after each session. Social work regulatory boards may request some form of supervision documentation when
supervisees apply for licensure. Records should be safeguarded and kept confidential.
Ethics
Supervisors have the responsibility to address any confusion that supervisees may encounter as a result of ethical
demands. A supervisor should be aware of the differences between professional ethics, core values, and personal
moral beliefs and help the supervisee to distinguish these elements when making practice decisions. Supervisors
can use the supervisory relationship as a training ground for ethical discretion, analysis, and decision-making.
Boundaries
The supervisory relationship is an excellent forum for supervisees to learn about boundaries with clients. Ethical
issues related directly to supervision include the nature of the professional responsibility to the supervisee,
appropriate boundaries, and responsibilities when dealing with incompetent or unethical behavior.
Becoming involved in a romantic or familial relationship with a supervisee is an ethical violation and should be
strictly avoided because it creates marked role conflict that can fatally undermine the supervisory relationship. If
the supervisor recognizes a potential boundary issue with a supervisee, he or she should acknowledge it, assess
how the boundary issue has affected supervision, and resolve the conflict.

19. 19
Although the supervisory relationship is between professionals, supervisors usually have more power in the
relationship than supervisees. To avoid boundary problems and conflicts of interest with a supervisee, the ethical
supervisor must accept his or her power and be comfortable in using that authority to ensure accountability and
protect clients.
Other ethical considerations include the following:
 A supervisor should always focus on the goals of supervision and the nature of the supervisory
relationship, and avoid providing psychotherapy services to the supervisee.
 Supervisors working with more than one supervisee should see each supervisee as an individual and adapt
to that supervisee’s needs. At the same time, supervisors must be fair and consistent when providing
supervision to multiple supervisees.
CLUB 1509 FORMS
The navigation team uses tools to explore the client strengths, identifying specific needs, and support the
development of a plan to attain a better quality of life.
CLUB 1509 navigation services will utilize the following tools during the course of services:
1. CLUB 1509 Eligibility Form
2. Service Agreement *
3. Provider Intake form
4. Bio-Psycho-Social Assessment
5. MINI International Neuropsychiatric Interview
6. Action Plan *
7. Tracking Form *
8. Progress Notes *
9. PrEP & ARV Adherence Support Index
10. Midpoint Conference
11. Discharge Conference
(*) CLUB 1509 Forms with a star informs the navigation team the use of the document provided in this manual is optional. If the
Navigation team does not use an optional form they must use a form that is equivalent to the one provide.
CLUB 1509 Eligibility & PREP Assessment
This assessment will help navigation team know the client’s readiness to take PrEP and provide an assessment for
appropriateness for CLUB 1509 program services. This form, usually done in connection with HIV testing, can
also be completed by either the Navigator or Navigator Assistant.
Client eligibility is determined using a standard intake form. Eligible clients should meet 2 of the following
criteria:
 African American/Black and/or Hispanic/Latino
 MSM
 Transgender
 Referred to PrEP
CLUB 1509 is an enhanced service designed for Black and Latino MSM and trans persons of color. However, all
CLUB 1509 services are available to any person regardless of age, gender, race, ethnicity, sexual orientation,

20. 20
gender identity, or socio-economic status, so if someone else asks to join you must refer them to the navigation
team.
It is expected that agencies funded to provide navigation services will be able to demonstrate evidence that they
are targeting services to Black and Latino MSM and Transgender persons of color, while having appropriate
screening mechanisms to ensure that those persons outside of the target demographics, but who present high needs
for navigation, are able to access services.
Service Agreement*
All participants in the CLUB 1509 program should read and sign a navigation service agreement. This document
informs the client what services will be offered, expectations from Navigator and Navigator Assistant, and
statement of confidentiality.
Comprehensive Assessment Form
The Providers Assessment Form is the first step of the enrollment process for CLUB 1509. The Navigators utilize
the Providers Assessment Form to conduct an assessment of the client’s strengths and needs. The form is utilized
to gathered information on personal composition, support systems, source of income, educational backgrounds,
medical background, medical histories, court involvement, behavioral health needs and services, experience with
domestic violence, history of loss, substance abuse/use, and home environment. Navigators gather as much
information as possible during the initial week of service to the client to assist with developing the Action Plan.
The Comprehensive Assessment Form is made up of three sections:
BioPsychoSocial Assessment
The BioPsychoSocial Assessment is a client planning tool for understanding a client’s circumstances that is
located within the Providers Intake Forms. The BioPsychoSocial Assessment assesses for various core
contextual elements of the client’s life, with the goal of documenting a thorough profile of the client that will
assist in making appropriate referrals and reveal any barriers the client may have. Information is gathered
through observation and direct reports from the client. In addition, this document (authored by Navigator)
explores the perception of self and the individual’s ability to function in the community. There is a detailed
example of how to write a BioPsychoSocial assessment in the documentation section of the manual.
MINI 5.0.0
This tool is a brief mental health interview for all CLUB 1509 participants. In order to keep the interview as
brief as possible, inform the client that you will conduct a clinical interview that has precise yes or no
questions about psychological problems. There are five modules identified by letters, each corresponding to a
diagnostic category.
It is imperative the navigation team read the general instructions (page 4) if they are not familiar with how to
use the tool.
Action Plan *
Information from the BioPsychoSocial assessment will guide the development of the Action Plan. Action
Plans are client centered, in order to retain personal responsibility and support self-sufficiency. The Action
Plan includes a description of the services that are recommended by the Navigator as well as any services the
client feels are needed. The Action Plan is developed during the first session of the service provision and it is
recommended this document will be reviewed by the client and navigation team every 30 days.

21. 21
Tracking Form *
The navigation team can use this form to keep track of a client’s progress on referrals and linkages. Furthermore,
this allows the navigation team to know what phase (engagement, development, and disengagement) of the CLUB
1509 program each client is in.
Progress Notes *
Provider agencies may have their own specific guidelines for writing a progress notes that reflect the activities
conducted with a client on their behalf. Progress notes in the CLUB 1509 program should tell a story. For
instance, if there is a two month gap in notes, the person reading the chart should be able to understand the reason
for the gap in service. Also, these notes should be in a DAP format (Data, Assessment, and Progress). There is a
detailed example of how to write a progress note in the documentation section of the manual.
PrEP & ARV Adherence Support Index
This document goes hand and hand with the progress note. Clients who are taking HIV/PrEP medications should be
asked about adherence at each interaction. The Adherence Index Questionnaire should be used at each Face-Face
interaction, and allows the navigation team to determine if more adherence support needs to be offer to the client.
Midpoint Conference Assessment
This document is completed with the navigation team and reviewed by a supervisor. This document should be
completed after 3months of service to evaluate progress on the Action Plan. Furthermore, the Mid-Point
Conference Assessment can determine if on-going services are needed for an additional 3 months.
Discharge Planning
This document is completed with the navigation team and reviewed by supervisor. This document should be
completed on 6 months of service to evaluate if the Action Plan is completed. Furthermore, this meeting can
determine if on-going or more intense human services are needed. Clients may be retained for an additional six
months if deemed appropriate after re-assessment.
DOCUMENTATION BEST PRACTICES:
Data Entry Best Practices
1. Follow Data Entry Guideline
2. Do not enter anything illegible or unclear
3. Only enter what you see or what client tells you
4. Use highlighter to flag any questions
Accuracy Completeness Timeliness =Quality of
Care

22. 22
Error CORRECTION (Handwritten Notes)
1. Cross out the error with one line, leaving the original entry readable.
2. Write the correct data next to or above the original data, now crossed-out and circled.
3. Initial, date and, indicate the reason for the correction, if necessary.
4. Never use correction fluid or tape (e.g., white out)
5. Never destroy original documents (even if they require error correction!)
6. Do not alter past-dated notes or back-date e.g., by writing alongside or adding to prior entries.
7. If you identify a problem with documentation you cannot resolve on your own notify a supervisor.
Here is an example of a CLUB 1509 document with error correction best practices.

23. 23
DOCUMENTATION

24. 24

25. 25
CLUB 1509 Eligibility & PrEP Assessment
Year of birth: State: County: ZIP Code:
Sex at birth: Male Female
Gender: Male Female Transgender (M-F) Transgender (F-M)
Do you identify as gay, a man who has sex with men, lesbian, bisexual, or queer? No Yes
Are you Hispanic or Latino? No Yes (Mexican, Puerto Rican, Cuban, Dominican, Other)
What is your race? American Indian or Alaska Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White
Instructions:
Askeach questioninorderandcheckthe corresponding answers. Follow the instructions next to each applicable answer
and only skip questions where instructed.
Question Answer & Action Step
1. When was the last time you
were tested for HIV?
Never ......................................................HIV Test & Skip to Q.3
Over 5 years ago..................................HIV Test, proceed to next question
Over 1 year ago....................................HIV Test, proceed to next question
About 1 year ago..................................HIV Test, proceed to next question
About 6 months ago............................HIV Test, proceed to next question
About 3 months ago............................HIV Test, proceed to next question
Tested in the past 3 months ..............HIV Test, proceed to next question
2. What was the result of that test? Positive..................................................Finish Assessment & Send to
Navigator. If Navigator is not present, link to HIV care.
Negative.................................................Proceed to next question
Unknown/Indeterminate....................Proceed to next question
3. Do you feel that you have had
an exposure to HIV within the
last 72 hours through either of
the following:
Unprotected sex/condom broke with HIV positive person or someone of
unknown HIV status ..........................................................nPEP referral, proceed to
next question
Sharing of needles/works ..........................................nPEP referral, proceed to
next question
No to the above.............................................................proceed to next question
4. Approximately how many
people have you had anal or
vaginal sex with in the past 12
months?
0 ...................................................Skip to Question 7
1 ...................................................Proceed to next question
2 or more....................................PrEP Referral, proceed to next question
5. About how often do you use
condoms when you have anal or
vaginal sex?
Never ...........................................PrEP Referral, proceed to next question
Rarely..........................................PrEP Referral, proceed to next question
Sometimes ..................................PrEP Referral, proceed to next question
Almost Always ...........................Proceed to next question
Always.........................................Proceed to next question
Agency ID: Site ID: Intervention ID:
Date of Test: Tester Name (First & Last):

26. 26
6. Are you having sex with
someone who you know is living
with HIV?
Yes................................................PrEP Referral, proceed to next question
No.................................................Proceed to next question
Don’t Know.................................Proceed to next question
7. Have you tested positive for any
of the following STDs in the past
12 months? (Please choose all
that apply)
Chlamydia..................................PrEP Referral, proceed to next question
Gonorrhea..................................PrEP Referral, proceed to next question
Syphilis .......................................PrEP Referral, proceed to next question
No to the above..........................proceed to next question
8. Have you ever had sex for
money, drugs or something else
you need?
Yes................................................PrEP Referral, proceed to next question
No.................................................Proceed to next question
Don’t Know.................................Proceed to next question
9. Have you injected drugs not
prescribed by a doctor in past 12
months?
Yes................................................Proceed to next question
No.................................................End Assessment and complete HIV test
Don’t Know.................................End Assessment and complete HIV test
10. Have you ever shared needles or
works (syringe, water, spoons,
filters, cotton, etc.)?
Yes................................................PrEP referral, complete HIV test
No.................................................End Assessment and complete HIV test
HIV Test Result
Positive/Reactive Negative Indeterminate Invalid
Instructions:
Please checkall applicableboxesbelow.Clientsshouldbe offeredCLUB1509 if theymeet ANY2 of the followingcriteria. If
there are any highriskpersonsthat donot meettwoof the criteria below but may be appropriate for these services they
can be offered CLUB 1509.
MSM Black/African American, Hispanic/Latino Transgender Eligible for PrEP
Note: All CLUB 1509 services are available to persons regardless of age, gender, race, ethnicity, sexual orientation, gender identity, or socio-
economic status.
Was the client offered Navigation Services? Yes No
Did the client accept Navigation Services? Yes No
Was the client referred to Navigation? Yes No
If Navigation services were declined please explain why:
Contact Information Sheet
Please fill out form ONLYif clientagreesto navigation.Once complete give the form to 15-1509 Navigator or Navigator
Assistant.
CLUB 1509 PROGRAM
Client Name: ___________________________________________________________________________________
Address: _______________________________________________________________________________________
City: __________________________________ Zip Code: __________________
“Based on the answers you
provided, you are eligible to join
CLUB 1509. CLUB 1509 is a new
short-term service mainly to help
Men who have Sex with Men and
Transgender persons of Color stay
healthy. CLUB 1509 can help you
get services like education, job
training, and medical insurance.
Would this be something you are
interested in?”

27. 27
CONFIDENTIALITY STATEMENT AND SERVICE AGREEMEN
PS15-1509 Comprehensive Assessment
This assessment form should be completed as soon as possible and within 30 days of client’s referral from HIV
testing. After all information is recorded, an Action Plan is to be completed. Do not leave any blanks – indicate if
the question is not applicable or the information is not available, or if the client chooses not to answer or
if the answer is unknown. Do not use Wite-Out.
Date of Assessment: _______/_______/_______ Bar Code Last Digits: ___________________
Agency: _____________
NAME: ______________________________ ________________________________ (Last)
(First) (MI)
Date of Birth: ______/_______/_______
DEMOGRAPHICS
Gender:  Male  Female  Transgender (m-f)  Transgender (f-m)  _______________________
Sex assigned at birth:  Female  Male  _______________________
Sexual Orientation:  Heterosexual/Straight  Homosexual/Gay  Lesbian  Bisexual
 Queer  Does not identify  _______________________
Race:  Asian  Black or African American  Native American or Alaska Native 
Hawaiian or other Pacific Islander  White  Prefer Not to Answer 
___________________________________________________________________
Ethnicity:  Hispanic or Latino  Non-Hispanic  _______________________
CLIENT CONTACT INFORMATION
Telephone: (______)________________________ Best time to call: _____________________________
Alternate Telephone: (______)________________________
Is it okay to leave a message?  Yes  No Is it okay to identify agency?  Yes  No
Address: __________________________________________________________________________
Lives with: ___________________________________________________________________________
Is it okay to send mail?  Yes  No E-mail :_____________________________________________
Facebook/Instagram/Twitter/Snapchat:_____________________________________________________
Primary emergency contact: _____________________________________________________________
Relationship to client: _____________________________ Telephone: (_____)__________________
Aware of HIV status:  Yes  No (If applicable) Permission to Contact:  Yes  No
Alternate emergency contact: ____________________________________________________________
Relationship to client: _____________________________ Telephone: (_____)__________________
Aware of HIV status:  Yes  No (If applicable) Permission to Contact:  Yes  No

28. 28
GENERAL INFORMATION
Are you currently employed?  Full-time employment  Unemployed, looking for work  Part-
time employment  Other ______________________________
What is your highest level of education completed?  Less than High School  High School/GED 
Vocational/Technical  Some College  College Degree  Graduate
Degree
Do you have access to Transportation?  Yes  No
Citizenship:  US citizen  Legal Resident  Undocumented
Are you a veteran?  Yes  No
HOUSING INFORMATION
Stable Permanent Housing
 Rent or Own House/Apt/Room  Permanently living with families/friends  Foster Care/Group Home
 Residence/long-term care facility
Temporary Housing
 Transitional Housing  Temporary Placement in an Institution  Couch-hopping
 Temporarily living/families or friends
Unstable Housing Arrangements
 Emergency Shelter  Homeless/Outdoors/Streets  Jail/Prison/Detention Facility
 Hotel/motel paid for with emergency shelter voucher  Other
How long have you lived at this location? _________________________
Who lives with you? ___________________________________________
May we contact the person(s) you currently live with?  Yes  No
If YES, Phone Number_________________________
HEALTH INSURANCE
Do you currently have health insurance?  Yes  No If YES, type? ______________________
Health Insurance Enrollment if No
Do you pay out-of-pocket costs for any of your medical care?  Yes  No
If YES, what do you pay for? ___________________________________________________________
MEDICAL INFORMATION
Do you currently have a medical care provider?  Yes  No
Medical Care Provider: _____________________________________________
Address: ____________________________________________________________________
_____________________________________________________________________

29. 29
Telephone: (______) ______________________ FAX: (______) _____________________
Contact Person (if other than doctor):___________________________________________
MEDICATIONS
Are you currently on PrEP?  Yes  No
Are you currently taking HIV medications?  Yes  No (If applicable)
If NO, what is the reason? (Check all that apply)
 Doctor has not yet prescribed them
 Using alternative therapies (herbs, acupuncture, exercise, meditation, etc)
 Don’t believe in taking medications
 Afraid of taking them/ don’t trust medications
 Can’t tolerate side effects
 Disclosure issues
 Unable to adhere to the regimen/ time schedules
 Resistant to HIV medications/ previous failure on anti-viral therapy
 No insurance/ can’t afford them
 Other ________________________________________________________________________
MEDICATION ADHERENCE
Assess ONLY if client is taking PrEP/nPEP/HIV medications
Was client’s adherence assessed utilizing the Adherence Index Questionnaire?
 Yes  No Date: ____________________________
DOMESTIC VIOLENCE
Discuss IMMEDIATELY with a supervisor if client is in a domestic violence situation.
Are you afraid of someone you are currently in a relationship with?  Yes  No
If YES, explain:
__________________________________________________________________________________________
______________________________________________________
Are you currently being hit, kicked, slapped or pushed by anyone?  Yes  No
If YES, explain:
__________________________________________________________________________________________
__________________________________________________________
Are you being pressured to participate in any sexual activity when you do not want to?
 Yes  No
If YES, explain:
__________________________________________________________________________________________
______________________________________________________________
Do you feel safe in your home?  Yes  No

30. 30
If NO, explain:
__________________________________________________________________________________________
______________________________________________________________
FINANCE
Was there been a time in the last 30 days you did not have enough money for food?  Yes  No
Do you have a consistent source of income? ________________________________________________
What is your yearly income?
 0 to $10,000  $10,000 to $20,000  $20,000 to $30,000  $40,000 to $50,000  $50,000 or More
How many people live in your household including you? __________________________
LEGAL
Do you have a need for legal assistance?  Yes  No
Have you been incarcerated in the past 12 months?  Yes  No
Are currently on probation or parole?  Yes  No
Do you have any pending legal case?  Yes  No
MISCELLANEOUS
Is there anything you would like to discuss that we have not addressed?  Yes  No
If YES explain______________________________________________________________________
REFFERALS
Referral Needed? Referral Date Referral
Agency
Linked Date Linked Agency
Employment
Education
Housing
Health Insurance
Medical
Medication
Domestic Violence
Once you have completed this section please begin the M.I.N.I to determine if further
referrals will be needed.

31. 31
Finance
Legal
Mental Health
Suicide/Homicide
Substance Abuse
Sexual Health
Transportation
Other
Bio-Psycho-Social Assessment
Please include client’s strengths/ resources, potential barriers to services, and major issues to be addressed in
the Action Plan:
The following information should be included in the:
 Presenting Problem
 Personal Status
 Drug History and Current Pattern of Use
 Substance Abuse Treatment History
 Medical History and Current Status
 Family and Current Relationships
 Positive Support Systems
 Legal Issues
 Education
 Employment
 Readiness for CLUB 1509 Program
 Resources
Please review the example of the Bio Psycho Social Assessment on next page.

32. 32
Bio-Psycho-Social Assessment
Please include client’s strengths/ resources, potential barriers to services, and major issues to be addressed in
the Action Plan:
Biological Psychological Social Assessment
(Example Case Vignette)
David Brown
Presenting Problems David is a 28 year-old, gay, black male. David has been using
methamphetamine for the past 3 years. Initially, he was
smoking the drug. Five years ago he began using intravenously.
David injects methamphetamines 3-5 times daily.
Personal Status David is the middle of three siblings.He has an older sister and
younger brother. David was born and raised in West
Philadelphia. He moved to the West Coast at age 20. He was
thrown out of the family home after revealing he was gay.
Shawn became sexually active at the age of 13. He has been
engaging is promiscuous, unprotected sexual activity since the
age of 20. Shawn was involved in the ballroom circuit in New
York, and stated he was in the House of Ebony. When moving
to Philadelphia he began to go to bathhouses in the
gayborhood. The majority of David’s social circle is made up of
individuals he met in establishments. David reports that they
are all methamphetamine users. Shawn has been sexually
involved with several of them.
Drug History and Current Pattern of Use David first began experimenting with drugs at the age of 15. He
drank alcohol every weekend and smoked marijuana on an
almost daily basis throughout his teens. At 20 began drinking
heavily and experimenting with Ecstasy. At 22, Shawn was
introduced to methamphetamine, and initially smoked it 3 – 6
times weekly. Two years he began injecting and within 4 years
he became a daily user. He is currently injecting
methamphetamine 3-5 times daily.
Substance Abuse Treatment History David was in recovery center in Delaware County for thirty
days, five years ago. He successfully completed treatment and
attended Narcotics Anonymous meetings for several months.
He relapsed after six months. After being arrested in New York
he possession of an illicit substances he entered a local detox
center. He successfully completed a twenty-one day
rehabilitation program. He did not follow-up with aftercare or
NA meetings. After testing positive for methamphetamines and
marijuana at probation, David was admitted to another detox
facility for five days. He must complete an Intensive Outpatient
Program or he faces a three year prison term.
Medical History and Current Status David has asthma and uses an inhaler as needed. He has had
multiple STI’s including gonorrhea and Chlamydia. David
reports his last test was 2 months ago and it was negative.
Family History and Current relationships David was raised in a two parent household in West
Philadelphia.Thefamily was Baptist and attended church every
Sunday. David’s father was an alcoholic and both physically and
verbally abusive.The family was upper middle class. His father

33. 33
was a car salesman. His mother was a dietician. Both parents
are deceased. David was estranged from his father from the
age of 20. He maintained periodic phone contact with his
mother until her death three years ago. His father, brother
stopped speaking to him when he revealed he was gay. David
was living with his partner for 4 years until la month ago.
However, he was asked to leave due David’s drug use and
infidelity.
David partner is drug free and has always been supportive of
David’s efforts to maintain sobriety. David recently began
attending services at church. He made a few friends and states
the Pastor has been a great support to him. The Pastor asked
him to join the church’s Men’s group however he is hesitant.
Legal David was arrested for being drunk and disorderly on two
separate occasions in New York and Philadelphia. Both times
he was fined $500. David was arrested for possession of
methamphetamine in New York twice since being place on
probation. If he does not complete Intensive Outpatient
Program he is facing up three years in prison.
Education David is a high school graduate. He briefly attended a
community college but dropped out after two semesters. He
appears of average intelligence. He reports being an A/A
student in high school.
Employment David is currently unemployed. In the past he has worked
mainly as a waiter and /or a bartender. His longest place of
employment was at a restaurant in San Francisco. He worked
there for two years. Over the past four years David has been
fired from 10 different places of employment excessive
absenteeism and one for stealing.
Navigator Signature_____________________________________ Date___________________________

34. 34
AGENCY
Information about the client that is provided to the AIDS Activities Coordinating Office (AACO) and CLUB 1509 Program provider
during the course of the CLUB 1509 program is confidential. No information about you will be shared with anyone else, without your
approval, unless you share information that leads to AACO and CLUB 1509 service provider to believe the following:
1. That you may need involuntary mental health treatment;
2. That you are having homicidal or suicidal thoughts
3. That child abuse (minor under 18) has occurred.
SERVICE AGREEMENT
CLUB 1509 Navigation services will provide professional public health services to the client. The direct intervention of the Navigator is
to considered and important component of service delivery. The Navigator will work with the client to promote behaviors that reduce the
client’s risk for contracting HIV, HIV medication adherence, creating a therapeutic alliance, and encourage participation in relevant
CLUB 1509 services.
The Navigators advocates on behalf of the clients to help those individuals overcome issues related to their risk of contracting HIV, and
links to HIV care. Navigators support clients with accessing material services including food, clothing, housing, transportat ion, PrEP,
health and medical care, and financial assistance. Navigators educate clients with how to apply for and maintain these benefits; they also
meet with other service providers to address barriers as they arise.
If a Navigator cannot access public services or the CLUB 1509 collaborative for the client, then the Navigator will notified the CLUB
1509 coordinator who will provide support in attempting to access the identified services.
The client will be asked to sign a release of information form to allow CLUB 1509 provider to contact other agencies that work within
the collaborative. Without access to this information, the CLUB 1509 Navigator or Navigator assistant may not be able to provide
appropriate services to the client.
The client should keep all schedule appointments with CLUB 1509 navigation services. If the client cannot keep an appointment due to
unforeseen emergency, the CLUB 1509 Navigator should attempt to notify navigation service immediately. CLUB 1509 Navigators
should notify the client if the Navigator is unable to keep schedule appointment with the client.
CLUB 1509 session should occur in a mutual space agreed with both client and Navigator. During the sessions, the client and CLUB
1509 Navigator may discuss past issues, current concerns, and future goals. The CLUB 1509 Navigator will provide ongoing
assessments and discuss progress and concerns with the client. Additional support for clients such as partners, family, and other
supportive persons may be asked to attend some clinical sessions with your permission.
CLUB 1509 Navigator assistant should see the client at least once a week and Navigators bi-weekly. Also, there may be times when
CLUB 1509 Navigators will need to meet more than six times a month.
A visit with the CLUB 1509 Navigator assistant may occur at other locations. For example, visits may include accomp anying the client
to medical appointments, school, or court hearing.
The client may be asked to meet with other co-workers of the CLUB 1509 program and other collaborative providers who will be
providing services to the client.
Information about the client may be used for teaching and research for purposes, and for AACO data collection and analysis. If any
report, publication or presentation is created, you will not be identified by name, and details that could make your identity known will be
changed or left out.
(Signatures):

35. 35
NAVIGATOR: __________________________ NAVIGATOR ASST.: _________________________________
CLIENT: __________________________ SUPERVISOR: ______________________________________
CLUB 1509 Navigation Services
[Name and Address of Your Organization]
AUTHORIZATION FOR RELEASE OF RECORDS OR INFORMATION
Client’s Name: ___________________________________
Date of Birth: _____________________________________
I hereby authorize [name of your organization] to (check one):
______ obtain from the following _______release to the following
Name: ___________________________________________________________
Address: ___________________________________________________________
the following documents/information from the records pertaining to the _______________ services
received.
Date/s of Service: ______________________________
The documents/information to be released are described or listed as:
The documents/information is required for the specific purpose of:
I understand that my authorization will remain effective from the date of my signature until
___________________, and that the information will be handled confidentially in compliance with all applicable
federal laws.
I understand that I may see the information that is to be sent, and that I may revoke the authorization at any
time by written, dated communication.
I have read and understand the nature of this release.
Signature of Client/Client’s Designated Representative Date
Witness Date

36. CLUB 1509 Navigation Services
[Name and Address of Your Organization]
AUTHORIZATION FOR RELEASE OF RECORDS OR INFORMATION
Authorization to Disclose Individually Identifiable Health Information
Including Protected Health Information
Patient’s Name ____________________________________________ DOB: _________________________
Address:________________________________________________ SSN: ___________________________
I authorize: ____________________________________________________________________________________
____________________________________________________________________________________
(Name and address of health care provider, health plan or health care clearing house)
To release to: _____________________________________
___________________________________________________
____________________________________________________
For the purpose of: ___________________________
_____________________________________________
_____________________________________________
HIPAA Release Authority. I authorize all health care providers or other covered entities to disclose information, oral or written,
regarding my physical or mental health, including, but not limited to, medical and hospital records and what is otherwise private,
privileged, protected or personal health information, such as health information as defined and described in the Health Insurance
Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936), the regulations promulgated there under and
any other State or local laws and rules , including confidential information concerning: Chemical Dependency
Diagnosis/Treatment, Mental Health Diagnosis/Treatment including Psychiatric and Psychological Evaluation and
HIV/AIDS Diagnosis/Treatment. HIVis the virus that causes or indicates AIDS or HIV infection. HIV-related information
is information which concerns whether a person has been tested for HIV or has AIDS or an HIV-related illness, or could
reasonably identify the person as having one or more of these conditions. Information disclosed by a health care provider
or other covered entity may be re-disclosed and may no longer be subject to the privacy rules provided by 45 C.F.R. Pt. 164.
The type of information to be disclosed is as follows: All Medical Records Lab Reports
Consultation Reports Discharge Summaries
Mental Health Evaluations _________________________
(Other)
Dates of Service: From ________________________ to _________________________________________________
I understand that I may revoke this Authorization at any time as long as I do so in writing. My revocation will not apply to any
disclosure of my medical information prior to the revocation and based on the original Authorization. I also understand that I
have the right to inspect the material that is to be released. This Authorization must be signed and dated.
This Authorization will expire on: ______________________________________________________________________
I have read and understand the above statements as they apply to me. I authorize the release/disclosure of information for the
purpose(s) stated above.
Patient signature: __________________________________________ Date: _________________________
NOTICE OF PROHIBITION
THIS INFORMATION HAS BEENDISCLOSEDTO YOUFROMRECORDS PROTECTEDBY PENNSYLVANIA LAW. PENNSYLVANIA LAWPROHIBITS YOU
FROM MAKING ANY FURTHERDISCLOSURE OFTHIS INFORMATIONUNLESS FURTHERDISCLOSURE IS EXPRESSLYPERMITTEDBY THE WRITTEN
CONSENT OFTHE PERSON TO WHOM IT PERTAINS OR IF AUTHORIZED BY THE CONFIDENTIALITY OF HIV-RELATED INFORMATION ACT, P.S.
SECTION 7601, ET. SEQ.,THE MENTAL HEALTHPROCEDURES ACT,50 P.S. SECTION 7101, ET. SEQ. ANDTHE DRUG ANDALCOHOL ABUSE ACT,71
P.S. SECTION 1690.101

37. ACTION PLAN
Please complete based on the comprehensive assessment. The plan should be reviewed (very face to face or phone contact) and revised every three (30) days. The date
completed or revised must be noted on the plan. Do not use Wite-Out
Long Term Goal: Empower client to maintain optimal physical and emotional health through ongoing assessment, linkage, and coordination of services,
advocacy, and monitoring.
Client Identified
Concerns
Action Steps Target Date Completed
I have reviewed the problems/needs and actions/goals targeted today with my CLUB 1509 Navigator.
I agree to the action plan. COPY ACCEPTED ___ COPY DECLINED ___
Client Signature________________________________________ Date____________________
Navigator ___________________________________________ Date __________________
Supervisor_______________________________________Date__________________

38. Navigation Service Tracking System
Client Name: Bar Code: Enrollment Date:
Date Method of Contact
(Text, Phone, In-Person)
Result Collaborative Network
(Y/N)
Agency
Navigator ___________________________

39. FORMAT FOR PROGRESS NOTE
Clients Name & Last for of Bar Code: Prevention Navigator or Assistant:
Date of Visit:
Time of Visit (Beginning & Ending):
Goal of Visit (RELATED TO CLUB 1509 Action Plan):
LOCATION(S) of VISIT:
OTHERS PROFESSIONAL PRESENT:
Data:
 What are your client’s thoughts?
 What are you observing?
 Direct quotes when necessary
 Is the client’s home environment affirming, and safe?
 What evidence do you have the client is safe?
 Does your client have housing?
 Dates of schedule appointments with referred agencies (hospitals, doctors, courts, schools, and
treatment providers).
 Names and contact information for schedule appointments
 The results of your referrals
 What support systems are in place for the client?
 Has the client followed up with the resources provided?
 What are the goals and objectives that you are working on at this visit?
 What are the observed client mood, behaviors, behaviors, feelings, attitude, and reaction to the services
/ intervention being provided?
 This information should be factual, specific, and focused. It should be a summarized but detailed
description of the activities that occurred in the home at the time of your face to face contact with the
client
Assessment:
How did the client’s session go?

40. 40
January 2017
How did the client respond to the outlined goals presented at the time of the home visit?
What are the barriers, challenges, and obstacles?
What is you perception of the client’s situation circumstances?
What is your understand of presenting issues that may have lead to Navigation services
You may write your thoughts but please remember to be fair and nonjudgmental
Plan:
 What goals and plan will continue to stabilize the client?
 What adjustments will you the Navigator make if the client continues to be resistant?
 WHAT IS THE DATE PF THE NEXT SCHEDULED VISIT?
 How are will you going to support the client in meeting the goals and objectives?
 Were there any referrals made by you as a result of your planning for the client?
Additional Items Discussed/Relative Information:
Date of next visit:

41. Adherence Index Questionnaire for Individuals on PrEP/PEP/ART
On average, how many times in the last 7 days would you say that you missed a dose of your medications? Circle
the answer
A. None
B. 1 time
C. 2 times
D. 3 times
E. 4 times
F. 5 or more times
If client answers A, B or C PLEASE STOP and continue with other documentation.
If this question is being explored by navigation team and the answer is D, Eor F please continue to the second portion of the
questionnaire.
Instructions: Allow the client to put a mark on the line below at the point that shows their best guess about how
much of their prescribed PrEP or HIV medication they have taken on the last month. This should not be at 100% due
to the last question.
Examples: 0% means you have taken no medication
50% means you have taken half your medication
100% means you have taken every single dose of your medication
What makes it difficult to take your PrEP/PEP or HIV medication regularly?
Went away for the weekend Forgot Disclosure/Afraid People will know
Left home w/o medication Worried about drug and alcohol interaction Fell asleep
No longer want to take medication Side Effects (Refer to Provider) Other
(Client’s Response Direct Quote and Navigation Team Recommendations)

42. 42
January 2017
MID POINT CONFERENCE SUMMARY
CLIENT
NAME
DATE OF
CONFERENCE
Last Four Digits
of Bar Code
PREVENTION
NAVIGATOR
PRESENT AT CONFERENCE:
Navigator Navigator’s Assistant Navigator Supervisor Client’s Family/ Support Persons
REFERRAL & CLIENT’S NEEDS: Description of Service Needs
SHOULD MATCH YOUR ACTION PLAN
1.
2.
3.
4.
PROGRESS MADE ON REFERRAL SERVICE NEEDS:
(Was there any progress fromprevious action plan?)
5.
6.
7.
8.
ACTION PLAN (Prior to case discharge):
What still needs to be done to reach Goals
1. Task:
Target Date: By Whom:
2. Task:
Target Date: By Whom:
3. Task:
Target Date: By Whom:
RECOMMENDATION FOR NEXT 3 Months or Discharge: Projected outcome to date
No Ongoing Services/Completion of Navigation Services Community Based Services Education
Transportation Employment Services Job Assistance Mental Health Services PrEP/nPEP
Transitional Housing Financial Assistance Alternative Response Systems/ Ongoing Services (ARS)
Health Insurance Assistance Substance Abuse Services
PRESENT AT CONFERENCE (Signatures):
NAVIGATOR: __________________________ NAVIGATOR ASST.: _________________________________
CLIENT: __________________________ SUPERVISOR: _____________________________________
(If not present send email of what occurred)
Should match the date you completed conference

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January 2017
DISCHARGE CONFERENCE SUMMARY
CLIENT
NAME
DATE OF
CONFERENCE
Last Four Digits
of Bar Code
PREVENTION
NAVIGATOR
REASON FOR DISCHARGE OR CLOSURE
Client lost to follow-up/unable to locate within 30 days Client relocated/ Out of Service Delivery Area
Client deceased Client incarcerated Client removed due to violence or violation of rules
(IF CLIENT IS DISCHARGED FOR ANY OF THE ABOVE REASONS THIS FORM IS COMPLETE)
Client requests closure/no longer desires services
Client requests change/transfer to alternative provider
Client transferred to Ryan White Medical Case Management
No ongoing services needed/Completion of navigation services
(IF CLIENT IS DISCHARGED FOR ANY OF THE ABOVE REASONS COMPLETE THE REST OF THIS FORM)
PRESENT AT CONFERENCE (Signatures):
Navigator Navigator’s Assistant Navigator Supervisor Client’s Family/ Support Persons
PROGRESS MADE ON REFERRAL SERVICE NEEDS:
(Was there any progress fromprevious action plan?)
9.
10.
11.
12.
ACTION PLAN (Prior to case discharge): WHAT GOALS WEREREACHED
1. Task:
Date: By Whom:
2. Task:
Date: By Whom:
3. Task:
Date: By Whom:

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January 2017
RECOMMENDATION BEFORE DISCHARGE: WHAT IS THE FINAL RECOMMENTATION?
No Ongoing Services/Completion of Navigation Services Community Based Services Education
Transportation Employment Services Job Assistance Mental Health Services PrEP/nPEP
Transitional Housing Financial Assistance Alternative Response Systems/ Ongoing Services (ARS)
Health Insurance Assistance Substance Abuse Services Additional Navigation Services
PRESENT AT CONFERENCE (Signatures):
NAVIGATOR: __________________________ NAVIGATOR ASST.: _________________________________
CLIENT: __________________________ SUPERVISOR: ______________________________________
(If not present send email of what occurred)

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January 2017
DEFINITIONS
AACO (AIDS Activities Coordinating Office): The office within the Philadelphia Department of Health
responsible for administering the city’s HIV/AIDS programs.
Action Plan- is a document that lists what steps must be taken in order to achieve a specific goal. The
purpose of an action plan is to clarify what resources are required to reach the goal, formulate a timeline
for when specific tasks need to be completed and determine what resources are required.
Advocacy- the act of pleading for, supporting, or recommending; active support.
AIDS (Acquired Immune Deficiency Syndrome): A result of Human Immunodeficiency Virus which
disables the immune system from effectively fighting numerous opportunistic infections and cancers.
BioPsychoSocial Assessment- A theoretical framework that posits that biological, psychological and
social factors all play a significant role in human disease or mental illness and health, rather than biology
alone.
CDC (Centers for Disease Control and Prevention): A federal disease prevention agency, which is part
of the U. S department of Health and Human Services, that provides national laboratory and health and
safety guidelines and recommendations; tracks diseases throughout the world; and performs basic
research involving laboratory, behavioral science, epidemiology and other studies of disease.
CLUB 1509- a demonstrations project to provide comprehensive prevention, care, behavioral health, and
social services for high risk Men who have sex with men and Trans communities of color (MSMC) and
HIV-positive MSMC.
Confidentiality- Keeping navigation and medical records private.
HIV (Human Immunodeficiency Virus) - a cytopathic retrovirus that is the cause of AIDS
Intersex- an individual having reproductive organs orexternal sexual characteristics of both male
and female.
MSMC- Men who have sex with men of color and a HIV/AIDS transmission category
Pre-Exposure Prophylaxis (PrEP) - it’s the use of anti-HIV medication that keeps HIV negative people
from becoming infected.
Transgender- noting or relating to a person whose gender identity does not correspond to that person’s
biological sex assigned at birth: noting or relating to a person who does not conform to societal gender
norms or roles.
Risk Behavior: Used here to describe activities that put people at risk for contracting HIV.
Service Agreement- an official commitment that prevails between a service provider and the client.
Particular aspects of the service – quality, availability, responsibilities – are agreed between
the service provider and the client.

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January 2017
Sexual Orientation- The sexual attraction people feel for others, whether of their own sex, the opposite
sex, or both sexes.
Social Determinants of Health (SDH) - are the economic and social conditions that influence the health
of an individual or group.

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January 2017
PROGRAM LOCATIONS
Action Wellness- 1026 Arch Street Philadelphia PA 19107 (267) 940-5500
AHS- 500 S Broad St, Philadelphia, PA 19145 (215) 685-6570
BEBASHI- 1235 Spring Garden Street, Philadelphia, PA 19123 (215) 769-3561
COLOURS- 1207 Chestnut Street 4th Floor, Philadelphia, PA 19107 (215) 851-1975
Kensington Hospital- 136 Diamond Street, Philadelphia, PA 19122 (215) 426-8100
Mazzoni- 21 S 12th Street, Philadelphia, PA 19107 (215) 563-0652
Philadelphia Fight- 1233 Locust Street, Philadelphia, PA 19107 (215) 985-4448