Dementia Mentor Contact Record
Date of Call
Did you speak with the Mentee during this call?
Hours spent serving this client:
Please write a detailed summary of the call.
Please select which Subjects you discussed with your Mentee (Check all that apply).
Caregiver Stress/Mental Health Issues
Care Options (In-home care, Adult Day programs, Long term care settings, etc)
Early Stage Programs (Dementia Mentors, Let's Talk, Living with Memory Loss, Meet Up, etc)
Intimacy/Spousal Relationship Issues
Person with Dementia's difficult behaviors
Person with Dementia's depression/mood
Safety issues (wandering, medications, home safety, cooking, etc)
Did you recommend any of the following Programs and Services? (Check all that apply.)
24/7 Helpline (800.272.3900)
Caregiver Support Group
Early Stage Programs (Let's Talk, Living with Memory Loss, Meet Up, etc)
Online Resources (Caregiver Center, ALZConnected, Community Resource Finder, etc.)
Respite Assistance Fund
Please note if this was a crisis call and if follow up is needed by a staff member or Helpline.
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