Sexual Assault Counseling Form

New York State

_____ You have opted to take medication to prevent pregnancy. You should know that the use of medication to prevent pregnancy is not always effective. About 1% of patients will still become pregnant. You have received a medication called Plan B (levonorgestrel). Some doctors give 2 pills at one time. Others give only one pill initially and ask you to take a second pill in 12 hours. Both ways are very effective. If you are asked to take a second pill, make sure to do it at the right time. Enclosed with your instructions are drug information sheets that will give you more information.

_____ You have opted to not take medication to prevent pregnancy. If you decide to change your mind, you have up to 72 hours after the assault. During that 72 hour period you can return to the emergency department and receive the medication. After the 72 hour period the medication is much less effective and not available through the emergency department.

_____ You did not receive medication to prevent pregnancy because a blood pregnancy test revealed that you are already pregnant.

_____ You have opted to take medication to prevent HIV infection. The medications chosen were based on whether you had a positive or negative pregnancy test. You must take the medications for a total of 28 days. You will receive from the emergency department an additional supply of medications that will complete the first day's course as well as an additional two days. The medications are very expensive. If you lack insurance coverage or funds to pay for them, the rape counselor will help you obtain them. This also will involve HIV testing. HIV prevention medications can have some side effects. Enclosed with your instructions are drug information sheets that will give you more information.

_____ You have opted to not take medication to prevent HIV infection. This medication is most effective if taken within 36 hours of the assault. However, there still may be some benefit if taken up to 72 hours after the assault. If you decide to change your mind during the 72 hours after the assault, you can return to the emergency department to receive three days of medication and prescriptions for the remaining 25 days.

_____ You have opted to take medications to prevent infection with gonorrhea and chlamydia. Enclosed with your instructions are drug information sheets that will give you more information.

_____ You have opted not to take medications to prevent infection with gonorrhea and chlamydia. If you change your mind, you can return to the emergency department at anytime to receive the medications.

_____ You have opted to take medication to prevent trichomonas and bacterial vaginosis. Enclosed with your instructions are drug information sheets that will give you more information.

_____ You have opted to not take medication to prevent trichomonas and bacterial vaginosis. If you change your mind you can return to the emergency department at anytime to receive the medication.

_____ You have opted to take gamma globulin and/or vaccination to prevent hepatitis B. It is important for you to understand that further treatment is based on the results of blood work. Further therapy might be two additional vaccinations (at 1 and 6 months) or an additional dose of gamma globulin at one month. This will be determined at the follow up visit. Enclosed with your instructions is a vaccine information sheet with more information.

_____ You have opted to not take gamma globulin and/or vaccination to prevent hepatitis B. If you change your mind, you can return to the emergency department within one week to receive this treatment.

Our sexual assault protocol requires us to obtain a blood pregnancy test, an oral HIV test, and serology for hepatitis B and C. Results of the blood pregnancy test are available while you are in the emergency department and are noted below. Results of the oral HIV test are available immediately and are noted below. Results of the hepatitis B and C serology can take up to 72 hours. They will be discussed at your follow up visit. If you choose to see your physician have him or her call the laboratory supervisor.

_____ Your oral HIV test was negative. It is important that you understand that this means you most likely do not have a pre-existing infection with HIV. It does not mean that you were not infected during the sexual assault. You will require serial testing over the next 6 months to assure that you were not infected. Until then you should use the usual precautions to avoid transmitting this infection.

_____ Your oral HIV test was positive.

_____ Your blood pregnancy test was positive.

_____ Your blood pregnancy test was negative.

_____ You consented to allow evidence collection utilizing the New York State sexual assault evidence collection kit. You have also given us permission to release the kit to the police.

_____ You consented to allow evidence collection utilizing the New York State sexual assault evidence collection kit. However, you chose to not allow release of the kit. The kit will be held for 30 days in the Security office safe. If you change your mind, contact the police in the precinct where the assault occurred. They will pick up the kit.

_____ You did not consent to allow evidence collection. It is best to collect evidence as soon as possible. If you change your mind, you have up to 96 hours after the assault during which evidence can be collected. You can return to the emergency department at any point during the 96 hours to have evidence collected.

_____ Aspects of your history and physical exam were suggestive of drug facilitated sexual assault. You consented to the collection and release of the New York State Drug Facilitated Sexual Assault kit.

_____ Aspects of your history and physical exam were suggestive of drug facilitated sexual assault. You did not consent to the collection and release of the New York State Drug Facilitated Sexual Assault kit.