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Home - Volunteer Portal - FORMS FOR SUBMITTING RECORDS AND HOURS - Bereavement Record of Contact

Bereavement Record of Contact

Wednesday, May 19, 2021

Use this form to submit your information for bereavement program contact.

Bereavement volunteer: *

Survivor served *

Relationship to deceased *

Name of patient *

Date of contact: *

Start Time *

End Time *

Travel time in minutes (if visit)

Type of contact *

Phone call
Visit
Mailing

1. Voicemail Message: Volunteer unable to reach bereaved via phone. Volunteer left a voicemail message.

Yes
No
N/A

2. Spoke to Bereaved: Volunteer spoke to bereaved via phone.

Yes
No

Summary:

3. Support bereavement volunteer provided:

Emotional support and reassurance
Discussed Lumina grief support services
Listening
Companionship
Other

4. Further attention needed from Bereavement Coordinator?

Yes
No

5. Follow Up Plan (if yes, make notes below):

Desire future phone calls?

Yes
No

Interested in a support group?

Yes
No

Interested in grief counseling?

Yes
No

Risk Level changes needed?

Yes
No

6. Additional Notes

Signature

Date / Time

Lumina Hospice & Palliative Care

Independent, nonprofit community hospice and palliative care serving our local communities.

720 SW 4th Street, Corvallis, OR 97333

541.757.9616 541.757.1760

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