Thank you for completing this survey to document the wellness calls/ Friendly Phone calls you have made to our clients. The first three questions are required.

Please remind our clients to call us with any request, questions or concerns. Milwaukee: 414-488-6500 and Waukesha: 262-549-3348

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* 1. Your Name (first and last)

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* 2. Client Name (first and last)

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* 3. Date of call

Date
Date
Date

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* 4. Spoke with client?

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* 5. If you did not reach the client, how many attempts did you make on EACH of the days?

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* 6. Any concerns Eras staff should follow up on?

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* 7. Length of phone call

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* 8. Brief overview of call

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* 9. Is this client interested in continuing to receive Friendly Phone Calls?

T