Volunteer Visitor Report

Thank you for volunteering with St. Joseph's Hospice!

Please complete and submit this form after your first visit with your client and every month thereafter.

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* 1. Your Name

First Name

Last Name

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* 2. Client Name

First Name

Last Name

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* 3. Volunteer Assignment

Regular Client Visit

Fill In Visit

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* 4. Date

Enter the date of your Hospice client visit. (Please submit a new form for each month.)

Date

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* 5. Date

Enter the date of your Hospice client visit. (Please submit a new form for each month.)

Date

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* 6. Date

Enter the date of your Hospice client visit. (Please submit a new form for each month.)

Date

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* 7. Date

Enter the date of your Hospice client visit. (Please submit a new form for each month.)

Date

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* 8. Date

Enter the date of your Hospice client visit. (Please submit a new form for each month.)

Date

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* 9. Please calculate the total number of hours spent visiting your client (hours, minutes).

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* 10. Please calculate the total number of visits.

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* 11. Did you miss a visit?

Yes

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* 12. If you missed a visit, please explain.

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* 13. Current Overall Client Status:

Improving

Deteriorating

No Change

Other (please specify)

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* 14. Current Mental Status:

Alert

Confused

Forgetful

Disoriented

Lethargic

Other (please specify)

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* 15. Current Emotional State:

Pleasant

Talkative

Denial

Anxious

Tearful

Shock

Flat Effect

Angy

Depressed

Withdrawn

Cooperation

Resignation

Other (please specify)

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* 16. Current Emotional State of Family:

Receptive

Cooperative

Angry

Withdrawn

Depressed

Tearful

Not Present

Other (please specify)

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* 17. Do you have any other comments, questions, or concerns?

Thank you for sharing your feedback!