Peer-Mentor Call Log

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Question Title

* 1. Your name

First name

Surname

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* 2. The participant's (mentee's) name

First name

Surname

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* 3. Date of this call

Call date

Date

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* 4. Time of Call

Start Time

Time

AM/PM

End Time

Time

AM/PM

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* 5. Call description
Brief description and summary of the discussion, support and suggestions provided (e.g. verbal info, referral to a service or health professional, etc.)

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* 6. Concerns, issues or other comments
Any concerns or issues to raise with the Health Promotion Coordinator, or any other comments or notes.

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* 7. Do you think the Participant will benefit from another Support Call?

Yes

No

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* 8. Is this your final call with the Participant?

Yes

No

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* 9. Next Meeting Date (Leave blank if none)

Date / Time

Date

Time

AM/PM