Form 0920-22GA Att 4e_Aim1ProviderPatientInteraction

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Expanding PrEP in Communities of Color (EPICC+)

Attachment 4e

Aim 1 Provider Patient Interaction

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Patient Interaction Rating Scale Beginner Novice Intermediate Advanced

1. The counselor cultivates empathy and compassion with client(s).	1	2	3	4
2. The counselor fosters collaboration with client(s).	1	2	3	4
3. The counselor supports autonomy of client(s).	1	2	3	4
4. The counselor works to elicit client(s)’ ideas and motivations for change.	1	2	3	4
5. The counselor balances the client’s agenda with focusing on the target behaviors.	1	2	3	4
6. The counselor uses reflective listening skills.	1	2	3	4
7. The counselor uses reflections strategically.	1	2	3	4
8. The counselor reinforces strengths and positive behavior change with affirmations/affirming reflections.	1	2	3	4
9. The counselor uses summaries effectively.	1	2	3	4
10. The counselor asks questions in an open-ended way.	1	2	3	4
11. The counselor solicits feedback from client(s).	1	2	3	4
12. Counselor manages counter change talk/sustain talk and discord.	1	2	3	4
13. The counselor demonstrates cultural humility.	1	2	3	4

Target Behavior(s) of Session: ________________

Circle one of the four competency ratings:

Beginner: <2.0 Novice: ≥2.0 to <2.6 Intermediate: ≥2.6 to <3.3 Advanced: ≥3.3

“X” your response for:

Whether client counter change talk/sustain talk or discord was present: __ Yes __ No

Counselor styles: _____ Following _____ Guiding _____ Directing

Whether each process was present in the session:

Engaging __ No __ Partial __ Yes

Focusing __ No __ Partial __ Yes

Evoking __ No __ Partial __ Yes

Planning __ No __ Partial __ Yes