PINE TREE HOSPICE       DIRECT CARE       CLIENT SERVICES RECORD        
VOLUNTEER:     MONTH and YEAR:        
CLIENT INITIALS Just initials, please                      
PTH licensure REQUIRES documentation of volunteer services, with a brief comment about each visit
After sending this form, you will have the chance to select a fresh form for another client
PLEASE enter your time in 1/4 hour segments using decimals (for example, 2.25)
and please enter your comments in the space provided
DATE:
CLIENT/FAMILY CONTACT TIME (Hours with client/family): TRAVEL hours:
       
DATE:
CLIENT/FAMILY CONTACT TIME (Hours with client/family): TRAVEL Hours:
       
DATE:
CLIENT/FAMILY CONTACT TIME (Hours with client/family): TRAVEL Hours:
       
DATE:
CLIENT/FAMILY CONTACT TIME (Hours with client/family): TRAVEL Hours:
       
DATE:
CLIENT/FAMILY CONTACT TIME (Hours with client/family): TRAVEL Hours:
       
DATE:
CLIENT/FAMILY CONTACT TIME (Hours with client/family): TRAVEL Hours:
 
          TOTALS: CONTACT: TRAVEL:        
              Total Contact + Travel:            
Do you need more room for this client?  Send this form, then you can select a fresh page