ࡱ> !` bjbj\\ >>qW$j4333P244f4Cg5566*6D]b] n]fffffff$/hhjhfv]RV@]v]v]f6*6( f*a*a*av]X6*6f*av]f*a*ah*a*65 83`F*aFa|g0Cg*ajaj*aj*av]v]*av]v]v]v]v]ffav]v]v]Cgv]v]v]v]D33 $D"f `   Attempts to Contact by Phone (Date, Time, Call Result) Example #1: 1/2/00, 8:00pm, Message left Example #2: 1/2/00, 8:00pm, No Answer NOTE: Home visit if "no contact" after a minimum of 5 call attempts.1) 6)2) 7)3) 8)4) 9)5)10)Reason for Contact Administer pre-survey Remind her of appointment  Administer survey  Check if she kept appointment  Provide consultation/referral information Other(specify): Contact Details      Appointment Information Appointment date: Time: Clinic: Appointment kept?: Yes No, why? Cancelled Rescheduled appt, date/time Date to Date to give reminder call**: check if appointment was kept**: Consultation A. Consumer skills  Coping Skills: (blue/green/pink/yellow) E. Distancing D. Appointment Magnet F. Seeking Social Support Abnormal Pap Education G. Escape Avoidance Other (specify): H. Problem Solving Referrals B. Transportation K. Substance abuse AC Transit Voucher L. Domestic violence C. Child care M. Sexual abuse I. Mental Health V. HIV/AIDS J. Alcohol abuse Other (specify): Outreach Plan * See Reverse **Enter Dates in calender book * Prolonged Contact or Travel Times Please explain any unusually long contact times due to interruptions, delays, long waits or other reasons.General Comments * See Reverse      FILENAME \p C:\My Documents\forms\Client contact forms\Client Contact Form 2-14-00 final1.doc Client's Name: _______________________ Phone#________________ ID#: ________ Contact Outcome CHA Name: Contact Information Contact Date: Contact Time: Contact To / From (circle one): Contact Type: Phone or In Person (specify location): Total Time with Client*: Travel Time*: Expenses: HoursMinutes  Travel OnlyHoursMinutesMileageParking No Contact Client Contact Form Pathfinders, Project #2 NOTE: Complete every time you talk to a woman or talk to someone on her behalf. 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