Grief Support Volunteer Care Report | Fox Valley Hands of Hope

Client Name *

Volunteer Name *

Name of Deceased

Date of Death

Relationship to Deceased

Months Since Death

1. Type of Contact

1. Date of Visit *

1. Hours/Minutes *

Include travel & documentation time

How is the client doing grief work with you?

Comments on Progress/Stage of grief *

Please provide a description of your impression on how the client is progressing in their grief process.

How is the client grieving outside of your meetings?

What skills did you engage in during the contact?

Grief Support Visit Summary *

Please provide a brief summary of your visit.

Additional challenges affecting the grief experience:

Check where appropriate and explain below in Comments field.

Comments on Additional Challenges

What symptoms of grief is the client reporting to be experiencing?

Check where appropriate and explain below in Comments field.

Comments on Experienced Grief Symptoms

How does the client report progress with their grief? *

What goals or improvements has the client worked on since your last visit? *

Volunteer Plans Include:

Check where appropriate

Special concerns requiring follow-up attention:

Examples: No phone contact with client for _______ month(s) or No visit with client for _______month(s)

Other Comments:

Date *

Email *

Volunteer Electronic Signature *