Annexure 42 : Counselling Checklists : Checklist for the Nurses, for

various Counselingsessions
Checklist No.1 : SELF ASSESSMENT OF EFFECTIVE COUNSELLING

Note- You can check your own progress in counselling clients at the clinic

Always At times Rarely

 You create rapport by:
• Greeting your client in a culturally
acceptable way
• Arranging for client privacy
• Sitting facing or close to your client

 You maintain two-way interaction by:

• Asking open-ended questions and
using encouraging remarks
• Listening attentively and observing
without interrupting or writing
• Encouraging the client to talk and
ask questions
 You find out what the client knows about:
• The problem, the issue, or concern
under discussion
• Its effects on his or her health
and /or family/child
 You explain facts about the problem
or issue, especially:
• Symptoms and effects of the problem
• Possible technical/factual solutions
• Rumours, misconceptions and
relevant facts
• Need for treatment, continuity,
behavior change, or referral,
if necessary
• Causes of the problem or potential problem
 You clarify or check the client’s understanding of the facts
(causes, effects, solutions and possible next step) by:
• Asking the client to repeat (or re state) the basic
factual information in his/her own words
 Clarifying misunderstood information
• Asking the client if he/she has any
questions
• Answering the client’s questions
politely and completely

Annexure 42- Counselling Checklists-New Page 1 of 18

 Always At times Rarely

 You help the client determine what to do about the

problem , or issue, or concern by:
• Encouraging the client to consider the
need to act on the problem; explain
the consequences if it is ignored
• Encouraging the client to make a
decision that is safest and most
practical in the circumstances
• Provides required service or referral
when appropriate
 You genuinely invite the client to return to the clinic
whenever they need to, e.g. if they have more questions.
You also tell the client about the suitable hours of service.

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Checklist No 2. ASSESSMENT OF RISK OF THE CLIENT

RISK EVALUATION FORM

Client code:_____________

Client has a regular partner: Yes/No

Regular partner’s status: HIV-positive/unknown/HIV-negative

Date of last test: ___________

Client/partner* indicates history of STI infection: Yes/ No

Treatment referral required: Yes/ No

Client/partner* reports

Symptoms of TB: Yes/ No

Treatment referral required: Yes/ No

Occupational Exposure: Yes/NO Date Window Period : Yes/ No

Tattoo, scarification: Yes/ No Date: Window Period: Yes/No

Blood products: Yes/ No Date: Window period: Yes/No

Vaginal intercourse: Yes/ No Date: Window period: Yes/No

Oral sex: Yes/ No Date: Window period: Yes/No

Anal intercourse: Yes/ No Date: Window period: Yes/No

Sharing injecting equipment: Yes/ No Date: Window period: Yes/No

Client risk was with a known HIV-positive person: Yes/ No

Client is pregnant: Yes/ No

If Yes, Stage of pregnancy: 1st trimester/2nd trimester/3rd

trimester

Client/partner* is using contraception regularly: Yes/ No

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Checklist No 3. Pre-test counselling form

PRE-TEST COUNSELLING FORM

Note to counsellor: Confidentiality of the client information should be strictly maintained at all times.

1. Date: ___ /___ /___ 2. Time: (start of session): _________

3. PID number: ________ 4. ICTC code___________________

5. Age: ___ years 6. Sex: M / F / Transgender

7. Education: standard: illiterate/1.5/6.8/8.10/11.12/Graduate/Post-graduate

8. Occupation: ________ (Migrant/ Non-migrant)

9. Monthly income in Rs: 0.2,500/2,501.5,000/5001.7,000/7,001.10,000/ more

than 10,000

10. Marital status: unmarried/ married/widowed/divorced/separated/living together

11. Referred by: Self/Doctor/NGO/CBO/Spouse/Family/Friends/Others ______

12. Medical history: (Does your client currently have any medical problems or
symptoms?]
Nil/Recurrent fever/weight loss/cough/diarrhoea/STIs/TB/OIs/Others ______

13. Currently on treatment: ______

14. Tested before for HIV: How many times? ___ Last test (month/year): ___ /___
Where (Place): ___________________________ Result: _________________

The form is to be filled in AFTER the counselling session with whatever information
was discussed.

Counsellor instruction: Please explore the following issues with your client:

15. Risk assessment of the past six months: (perception of risk to self)

Q: Why has the client presented for counselling and testing?

_____________________________________________________________
_____________________________________________________________
Q: Why does your client think he/she is at risk of HIV?
_____________________________________________________________
_____________________________________________________________

(a) No risk (b) Perinatal (from mother to child)

(c) Contaminated blood through:
-.Blood transfusion .IDU
-.Organ transplant .Tattoo
.-Needle stick injury

Annexure 42- Counselling Checklists-New Page 4 of 18

(d) Unprotected sex:___ Vaginal___ Anal
(e) Partner or family member infected
_____________________________________________________________

16. Development of a risk reduction plan

(a) Increase condom use (b) Reduce number of sexual partners

(c) Reduce needle sharing (d) Reduce alcohol or drug use
(e) Discussion with spouse/partner (f) Others
_____________________________________________________________________________________________

_____________________________________________________________________________________________

________________________________________________________________________

17. Client’s vulnerabilities:

(a) Unprotected sex with Males Females Hijras CSW

(b) Use of drugs/alcohol during or before sex
(c) Gender related (violence, rape, etc.)

18. Client’s current psycho-social stressors

Q. What are currently your client’s major worries in life?

(a) Finances/debt (b) Addictions (alcohol/drugs)
(c) Family (d) Violence
(e) Loss of work or occupation (f) Sex related
(g) Serious illness/death (h) Social
(i) Others

List issues and psycho-social stressors discussed:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

19. Client’s anticipated psycho-social stressors

Q. What are anticipated concerns of your client in case of a positive HIV Test
result?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

(a) Prior history of self harm/suicide attempt

(b) Harm to others in case of positive test result
(c) Signs of suicidal thoughts
(Feeling of hopelessness/helplessness/overburdened/no options/social withdrawal)

20. Client’s coping mechanisms

Q. How has your client coped with a crisis in the past, e.g. loss of job, death of
Spouse or partner, or relationship issues? Who helped your client?

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 List coping strategies discussed (including alcohol, violence, attempted suicide):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

What plans does your client have for managing the crisis associated with HIV/AIDS?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

21. Client’s social support systems

Q. In case your client has a crisis in his/her life, who provides support to him/
her?

(a) Immediate family (Spouse) (b ) Extended family (c) Friends (d) Others

Q. Who will accompany the client to pick up the HIV test result?

(a) Immediate family (Spouse) (b) Extended family (c) Friends (d) No one (e) Others
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

22. Client’s readiness to undergo HIV test

Q. Would your client like another appointment before deciding on the HIV
test?
_____________________________________________________________
_____________________________________________________________

23. Client’s readiness to involve partner

Q. Will your client bring his/her spouse or partner for counselling? If not, explain
why?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

24. Date for follow-up visit given: ___ /___ /___

25. List of referrals given: (counsellor should have a referral list prepared)
_____________________________________________________________
_____________________________________________________________

26. Counsellor.s checklist:

___________ Client’s understanding of STI/HIV/AIDS addressed

___________ Information about STI/HIV/AIDS provided including

a. modes of transmission

b. nature of HIV/AIDS

___________ Misconceptions corrected

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___________ Information about HIV test provided

a. Nature of test and testing process

b. Benefits and consequences

What plans does your client have for managing the crisis associated with HIV/AIDS?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

c. What does a positive result mean

d. What does a negative result mean

e. Window period

___________ Client’s emotional preparedness for HIV test result assessed

___________ Checked for suicidal ideation
___________ Importance of post-test counselling explained
___________ Information on .living with HIV.provided (nutrition, ARVs) provided
___________ Risk reduction counselling done

a. Safer sex practices

b. Condom use
c. Safe needle use (for IDUs)

___________ Prevention counselling provided

___________ Condom demonstration done and condoms provided

Willingness to involve partner in follow-up assessed

___________ Informed consent obtained

___________ Identification of TB symptoms undertaken
___________ Referrals discussed and given
___________ Follow-up arrangements discussed (date provided)

27. Counsellor.s remarks:

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

28. Time (end of session): ______________

29. Length of session (minutes):__________

30. Counsellor.s signature and date:____________________________________

Annexure 42- Counselling Checklists-New Page 7 of 18

Checklist No 4. Pre-test counseling form

POST-TEST COUNSELLING FORM (NACO)

Note to counsellor: Confidentiality of the client information should be strictly maintained at all times.

1. Date: ___ /___ /___ 2. Time: (start of session): _________

2. PID number: ________ 4. VCTC code number: _________

5. Type of visit: Post-test counselling/follow-up visit

6. Test result: positive/negative/indeterminate

7. Age: ___ years 8. Sex: M/F/Transgender

The form is to be filled in AFTER the counselling session with whatever information was discussed

For NEGATIVE Result

9. Initial reaction

Surprise/resentment/guilt/happy/relaxed/others

Observe and discuss with client:

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

10. Assessment of any concerns (Window period)

Summary of discussions with the client:

____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

11. Development of a risk reduction plan

(a) Increase condom use (b) Reduce number of sexual partners (c) Reduce needle sharing (d) Reduce alcohol or
drug use (e) Discussion with spouse/partner (f) Others

List risk reduction plan developed:

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

12. Willingness to change behaviour to decrease vulnerability ___Yes/___No

13. Need for HIV test after window period discussed ___Yes/___No

For POSITIVE Result

14. Initial reaction

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Acceptance/shock/fear/denial/suppressed emotion/anger/violence/grief/
sadness/depression/anxiety/crying spells/suicidal ideation/withdrawal/
resentment/others

Observe reaction and discuss with client:

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

15. Assessment of immediate concerns

Stigma/fear of rejection (discrimination)/loneliness/loss of prestige/loss of job/
loss of income/loss of self esteem/family disclosure/fear of death/loss of health

Summary of discussions with the client

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

16. Assessment of other concerns

(a) Marriage counselling (b) Partner notification and testing
(c) Disclosure to spouse or family (d) Concerns about support systems
(e) STI medical follow-up (f) TB follow-up
(g)Nutrition counselling (h) Sex with spouse/partner
(i) Social/psychological support follow-up (j) Social support and referrals
(k) Rights and responsibilities (l) Others

Summary of discussions with the client

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

17. Risk-reduction strategies discussed

(a) Increase condom use (b) Reduce number of sexual partners
(c) Reduce needle sharing (d) Reduce alcohol or drug use
(e) Others

Summary of discussions with the client:

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

18. Willingness to increase safer behaviour _____Yes /_____No

19. Referrals* and follow-up given (*counsellor should have a referral list prepared)
(a) Individual counselling (b) Family counselling
(c) Within the hospital (d) To medical doctor (nonhospital)
(e) Psychiatric intervention (f) Support groups/PLHA
(g) Intervention and workplace (h) Community intervention
(i) TB/MC center (j) ANC
(k) IDU interventions (l) Needle stick
(m)Marriage counselling (n) Legal

Annexure 42- Counselling Checklists-New Page 9 of 18

List referrals made (types and places):
_____________________________________________________________

_____________________________________________________________

20. Agreed to disclose HIV status to spouse/partner _______

Client’s issues associated with disclosure to spouse/partner

_____________________________________________________________
_____________________________________________________________

21. Willingness to bring spouse/partner for counselling _______

Summary of discussions:
_____________________________________________________________
_____________________________________________________________

For POSITIVE and NEGATIVE result

22. Date for follow-up visit given: ___ /___ /___

23. List of referrals given: (counsellor should have a referral list prepared)
_____________________________________________________________
_____________________________________________________________

24. Counsellor checklist

For negative result:
___________ Result given
___________ Immediate concerns/questions assessed
___________ Window period explained
___________ Risk reduction strategy developed
___________ Willingness to change behaviour assessed
___________ Need for an HIV test after window period discussed
___________ Follow-up appointment given
For positive result:
___________ Result given
___________ Discussion of the meaning of the result for the client
___________ Dealt with immediate emotional concerns
___________ Client able to understand and absorb the result
___________ Discussion of personal, family and social implications
___________ Checking of availability of immediate support
___________ Discussion of follow-up care and support
___________ Partner evaluation
___________ Risk reduction strategy developed
___________ Willingness to change behaviour assessed
___________ Immediate plans, intentions and actions reviewed
___________ Discussion of symptoms of TB and importance of early referral
___________ Further support and referrals given (ANC, TB, STI)
___________ Rights and responsibilities discussed
___________ Legal support discussed
___________ Follow-up appointment given
___________ Disclosure discussed
___________ Bring spouse for counselling discussed

25. Counsellor.s remarks

______________________________________________________________
______________________________________________________________
______________________________________________________________

26. Time (end of session): ________ 27. Length of session (minutes):_________

28. Counsellor.s signature and date:____________________________________

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Checklist No 5. Adherence Counselling form

ADHERENCE COUNSELLING CHECKLIST 1

Name of the client

Date of counselling session

Assess the patient

Medical history

Knowledge of HIV/AIDS

Prior use of ART

Determine the social support

Disclosure. have they disclosed to anyone?

Alcohol/drug use

Mental state

Review the health status

OIs

CD4/viral load

Review living conditions and employment

Housing

Employment/income

Describe the treatment programme and importance of adherence

Drug regimen.name/frequency/storage/dietary instructions/not to share pills

What ART does. suppresses virus/improves immunity/lessens OIs/not a cure

Cost

Side-effects and what to do

Follow-up

Importance of adherence and consequences of non-adherence

Discuss adherence promotion strategies

Buddy reminder. discuss role of support person

Annexure 42- Counselling Checklists-New Page 11 of 18

Pill diary

Other reminder cues

Identify barriers to adherence Yes No

Poor communication

Low literacy

Inadequate understanding about HIV/AIDS

Lack of social support

Failure to disclose the HIV-positive status

Alcohol and drug use

Mental state

Schedule the next counselling session and complete the appointment card
aa

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 ADHERENCE COUNSELLING CHECKLIST 2
Name of the client

Date of counselling session

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aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

Review client’s understanding of HIV/AIDS

What is HIV and AIDS?

What are opportunistic infections?

What do they understand by CD4 counts/viral load?

What are the effects of treatment?

Review the treatment programme and importance of adherence

Drug regimen

Dummy pill demonstration

What ART does. improves immunity/lessens OIs/ART is not a cure?

Need for continued prevention. use of condoms

Side-effects and what to do

Follow-up

Importance of adherence and consequences of non-adherence

Review proposed adherence promotion strategies

Buddy reminder. discuss the role of a support person

Review the pill diary

Other reminder cues. discuss HAART

Review barriers to adherence and the progress made so far

Poor communication skills

Low levels of literacy

Inadequate understanding about HIV/AIDS

Lack of social support

Failure to disclose the HIV-positive status

Alcohol and drug use

Mental state

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Take the client’s address and establish contact system
ADHERENCE COUNSELLING CHECKLIST 3
Name of the client

Date of counselling session

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aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

Assess the client’s understanding of the disease and readiness to start

What is HIV disease?

What are opportunistic infections?

What is meant by CD4 count/viral load

What are the effects of treatment

What is their level of commitment to adherence

Review the treatment programme and importance of adherence

Drug regimen

Dummy pill demonstration

What ART does. improves immunity/lessens OIs/ART is not a cure

Need for continued prevention. condom use

Side-effects and what to do

Follow-up

Link between adherence and successful outcome

Review proposed adherence promotion strategies

Buddy reminder. discuss the role of a support person

Review the pill diary

Other reminder cues. discuss HAART

Fill the ART register, schedule the next appointment and complete the appointment card

Refer to the Pharmacy/Chemist

Annexure 42- Counselling Checklists-New Page 14 of 18

 ADHERENCE COUNSELLING CHECKLIST 4
Name of the client

Date of counselling session

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aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

Review the patient’s experience with treatment and adherence over the past month

Drug regimen and adherence. pill counts, self-report

Discuss the side-effects and the actions taken

Discuss the need for continued prevention. use of condoms

Review the experience with a follow-up plan

Discuss the follow-up plan for the next month

Review the patient’s goals and success at achieving them

Review barriers to adherence

Buddy reminder. discuss the role of a support person

Review the pill diary

Review barriers to adherence

Poor communication skills

Low levels of literacy

Inadequate understanding of HIV/AIDS

Lack of social support

Failure to disclose the HIV-positive status

Alcohol and drug use

Mental state

Fill the ART register, schedule the next appointment and complete the appointment card

Refer to a pharmacy/chemist

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Checklist No 6. Home Care counseling form

HOME VISIT DATA SHEET

Name of the patient Registration No

Sex: M/F

Purpose of home visit

Observed emotional and physical status of the patient

Chief caregiver

Observed dynamics at home

Observed dynamics with the caregiver

Locality and neighbourhood

Socioeconomic situation as observed

Expressed concerns/issues/opinions

Home visit conducted by

Visit requested by

Visit commissioned by

Date of request Date of visit

Annexure 42- Counselling Checklists-New Page 16 of 18

Checklist No 7. Suicidal risk assessment form

SUICIDE RISK ASSESSMENT GUIDELINE EXERCISE

Use assessment format given below for assessing the client’s risk for suicide.

Note: The suicide risk assessment provides a guideline for professionals on how to
interview persons at risk for suicide. As guidelines rather than a ready-to-use
questionnaire, many questions would need more exploration and probing in order
to evaluate the subjective reality of each individual at risk.

1. Do you sometimes feel so bad/hopeless/helpless you think about suicide? YES

/No

Follow this up with the following explorations:

2. How often?

a. Are you currently thinking of suicide? YES / NO

b. Have you thought of how would you do it? YES / NO

3. Do you have a plan? YES / NO

a. How lethal is the planned method?

(EXPLORE the perception of the person at risk!)

3. Do you have the means? EXPLORE

4. Have you decided when you would do it? EXPLORE
5. Have you ever tried suicide before? EXPLORE

If ‘yes’ check whether previous attempt was:

a. Impulsive?
b. Planned?
c. Did you use any ‘booster’ to make you do it, such as alcohol/drugs?

7. If you have tried suicide before, what difference, if any, did it make

Write down the client’s answer. Generally, any positive change perceived by the
Client makes the risk higher.

Check for symptoms of clinical depression.

a. Neuro-vegetative symptoms:
• Sleep disturbances
• Loss of appetite
• Tiredness/lack of energy
• Agitation/slowing down
• Loss of interest in sex

Annexure 42- Counselling Checklists-New Page 17 of 18

b. Mood and motivation
• Prolonged unhappiness
• Loss of interest or pleasure
• Hopelessness/helplessness
• Difficulties performing at work
• Difficulties carrying out routine activities
• Withdrawal from friends and social activities
• Check for somatization (pains, aches, physical discomfort without any
organic cause)

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