MVP & Tele-Care Volunteer Hours
For questions or concerns, please contact Celine Crete at ccrete@alzheimerniagara.ca or 905-687-6856 ext. 544.
Volunteer Name
*
First Name
Last Name
E-mail
*
MVP or TeleCare Client
*
Session Tracker
Please Select
Tele Care Call
MV Visit 1 - Introduction
MV Visit 2 - Leisure Interest Interview
MV Visit 3 - Kit Activity
MV Visit 4 -Kit Activity
MV Visit 5 -Kit Activity
MV Visit 6 -Kit Activity
MV Visit 7 -Kit Activity
MV Visit 8 -Kit Activity
MV Visit 9 -Kit Activity
MV Visit 10 - Wrap up & Evaluation
MV ongoing
Visit date
*
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Month
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Day
Year
Date Picker Icon
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:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Length of visit (in hours)
*
Type of visit
*
Phone call
Face-to-face
Comments/Activities
Changes in your companion
Behaviour:
Increased anxiety/nervousness
Increased irritability/anger/emotional outbursts
Increased depression/sadness
Increased agitation, restless, pacing
Hallucinations, delusions, paranoia
Interactiveness:
Attention (inability to focus)
Social connection (withdrawal, isolation)
Alertness (being present/tuned-in)
Initiative (taking part, starting activity)
Personal/Basic:
Weight loss or gain
Hygiene/grooming/bathing concerns
Dressing concerns
Memory/Communication:
Increased forgetfulness
Increased repetition (stories, questions, requests)
Orientation (people, place, time)
Changes in your companion's home
Note: For Face-to-Face visits
Accumulation of mail
Decreased cleanliness
Food in kitchen/fridge
Fire safety issues (collection of papers, etc.)
New visitors/guests/people living in the home
Unrecognized odours
How was your volunteer Experience today?
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4
5
1 star negative - 5 starts positive
Any other comments/Feedback on your personal volunteer experience
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