|
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
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|