MONEY MANAGEMENT - TIME AND MILEAGE CONTACT LOG

MONTH / YEAR

(Use tab to navigate from field to field)

CLIENT NAME:

VOLUNTEER NAME:

DATE	TYPE*	CLIENT/PERSON CONTACTED	PHONE# OR EMAIL ADDRESS	PURPOSE OF CONTACT & OBSERVATIONS	CASE MINUTES	CASE MILES

MONTHLY		TOTALS -   MINUTES:    MILES:
	*Key V= Face-to-face visit with client                        P= Phone call           O= Other           S=  Support/Training	**ENTER IN MINUTES (EXAMPLE 2 HOURS = 120

                  

Do you want reimbursement for mileage and other expenses? No Yes

Other expenses: (postage, copying, parking, etc.) $

                              Reimbursement requests must be received on the 4th day of the month in order to be compensated.

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STATUS OF CLIENT MONTHLY SUMMARY
REPRESENTATIVE PAYEE

1. Did client express needing more money? Yes No
Please explain.

2. Do you suspect someone is financially exploiting client? Yes No

3. Does client report any unpaid bills? Yes No

4. Does client need food? Yes No

5. Are living conditions satisfactory and home clean? Yes No

6. Community supports: If used, are they adequate? Yes No
(If assistance needed, note below)

7. Is client clean, clothes clean, etc.? Yes No

8. Does client need clothes? Yes No

9. Does it appear client needs to seek medical attention? Yes No

10. Does it appear client is taking medicines as prescribed? Yes No

11. Does client need medicines? Yes No

12. Is client's physical / mental health stable? Yes No
(If assistance needed, note below)

13. Has client been hospitalized in the last month? Yes No

14. Does client appear happy with Money Management Program? Yes No

Please elaborate on above questions as needed and Indicate any unmet needs, services or concerns that are not addressed above.

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