Date of Outreach call:
Time of call:
Did you leave a message if the consumer was not available?
If you spoke with someone else, who did you speak with?
Time Spent on the call: minutes
Time Spent on this report: minutes
How long did the consumer say they have been on the wait list?
Does the consumer still need services?
If not, why?
moved to a facility
moved out of state
receiving other services
Does the consumer need help with: (check all that apply)
Does the consumer need help with any activities of daily living? (check all that apply)
Does the consumer have anyone to help them while they are waiting for services?
If yes, please provide the name and relationship of the helper(s):
Does the consumer use an assistive device? (check all that apply)
Has the consumer had any recent falls?
Does the consumer see the doctor regularly?
How does the consumer get to the appointment?
Does the consumer receive Meals on wheels (MOW's)?
If no, would the consumer like a referral for MOW's?
Does the consumer have the phone number for the Area Agency on Aging? If not, please provide the consumer with the number.
Is the consumer familar with 211? If not, please provide the consumer with information about 211 Maine.
Did the consumer indicate any health or safety concerns?
If yes, please call the office immediately to discuss.
Did the consumer give permission to share information with Catholic Charities?
Please include any information from the call that you feel is helpful to share.
"All long-term care consumers have the right to be treated with dignity and respect."
61 Winthrop St. l Augusta, Maine 04330
Voice/TTY: 1-800-499-0229 l Augusta Area: (207) 621-1079 l Fax: (207) 621-0509