Telephone Outreach Report

 

Calendar

Did you leave a message if the consumer was not available?
Yes
No

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?

Yes No


deceased
moved to a facility
moved out of state
condition improved
receiving other services

Does the consumer need help with: (check all that apply)
preparing meals
grocery shopping
housework
laundry
personal hygiene

Does the consumer need help with any activities of daily living? (check all that apply)
bathing
dressing
transfers
locomotion
bed mobility
eating
toileting

Does the consumer have anyone to help them while they are waiting for services?
Yes No

Does the consumer use an assistive device? (check all that apply)
cane
walker
wheelchair

Has the consumer had any recent falls?

Does the consumer see the doctor regularly?
Yes No

How does the consumer get to the appointment?

Does the consumer receive Meals on wheels (MOW's)?
Yes No

If no, would the consumer like a referral for MOW's?
Yes No

Does the consumer have the phone number for the Area Agency on Aging?
If not, please provide the consumer with the number.

Yes No

Is the consumer familar with 211?
If not, please provide the consumer with information about 211 Maine.

Yes No

Did the consumer indicate any health or safety concerns?
If yes, please call the office immediately to discuss.

Yes No

Did the consumer give permission to share information with Catholic Charities?
Yes No

Need Help?

 


 

"All long-term care consumers have the right to be treated with dignity and respect."