ElderFriends Quarterly Report

*(denotes required field)

Name:*

E-Mail Address:*

Year:

Quarter:

1st (Jan-March)
2nd(April-June)
3rd (July-Sept)
4th (Oct-Dec)

Visitor Name:

Elder Name:

In-person visits: An In Person Visit is any visit in which you get together with your elder friend, either at their home or elsewhere.

In-person visits: Number

In-person visits: Hours

Phone visits: A Phone Visit is any time you call your friend to talk with them. Does not include very brief calls made for the sole purpose of confirming your next visit.

Phone visits: Number

Phone visits: Hours

Phone visits: Minutes

Optional Direct Service: Direct Service refers to any type of additional assistance beyond friendly visiting (i.e., household chores and errands).

Optional Direct Service: Number (approx. # of total visits)

What kinds of additional assistance did you provide to your elder friend this quarter?

How do you feel about your relationship with your elder friend?

What was a highlight this quarter?

Do you have any concerns or questions?

Additional notes or suggestions:

Please note any address, email or phone changes:

ElderFriends Quarterly Report

Section Guide: