Hospice Bereavement Progress Notes

Volunteer Name

Bereaved Name

Date

Total Call Time

Type of Contact

3 Month Phone Call

6 Month Phone Call

9 Month Phone Call

12 Month Phone Call

Treatment Plan

Continue Current Plan

No more Mailings or Phone Contact

No More Phone Contact

No More Mailings

Increase Phone Contact

Referral To: Support Group (Please Specify)

Bereavement Coordinator

Bereavement Staff

Bereavement Program in another State (Please Specify)

Summary of Contact*