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