Date of Visit:*

Your Name:*

First Last

Name of person who you visited:*

First Last

How much time did you spend with your friend? (quarter hour increments)*

What did you do during the visit?*

Talked
Arts and Crafts
Read to friend
Walked
Read to friend
Listened to music
Email/Letter

Please describe your visit (including any concerns about person/staff):*

Please note any new concerns from this visit:

Are there any changes you would like to note about this visit?

Change in case worker
Room change
Moved out
Incoherent
Moved to Rehabilitation Center
Facility change
Decline in health
Deceased

When you click "Submit" you will redirected to the reporting menu to enter any additional reports that you may have. If you have no additional reports to enter, simply close the window. Thank you for completing your report.

SAGE: Friendly Visitor Log