University of FloridaSolutions for Your Life

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Publication #FCS2258

Contact Organization for Caregivers1

Martie Gillen and Carolyn S. Wilken2

When you are seeking medical care for an older adult, you may need to contact multiple agencies and offices before you get the information you need. This document contains a form to use when contacting these organizations so that you can keep track of your conversations and record the information for future reference.

Make several copies of the caregiver's contact form (see below). This contact form will help you organize the information you need and will serve as a reminder of the questions you should ask.

Figure 1. 

As a caregiver for an older adult, you may have to contact multiple agencies and health care providers to ensure the adult under your care gets the help and services he or she needs. Use this form to keep track of your contacts.


Ciaran Griffin

[Click thumbnail to enlarge.]


Here is a sample outline to follow for the contact:

My name is: _____________________________________________________________

Who am I speaking to? __________________________________________________

I'm caring for: ____________________________________________________________

I need: __________________________________________________________________

Can you help me? ____Yes ____No

If "No": Can you refer me to anyone else? _______________________________________

How can I contact them? ____________________________________________________


If "Yes," continue with the following questions:

What services do you provide? _____________________________________________


What are the costs? ______________________________________________________

How are they paid? ______________________________________________________


What are the eligibility requirements?


Is there a wait for services? If yes, how long must we wait? __________________________________________________

Will you send me a brochure or application? __________________________________

Is there anyone else I should speak to?


When can I expect to hear from you? _________________________________________

Thank you for your help.

Complete this section immediately after the contact.

Agency contacted: _______________________________________________________

Specific doctor or professional contacted: _____________________________________

Method of contact: _______________________________________________________

Phone number: __________________________________________________________

Email address: __________________________________________________________

Mailing address: _________________________________________________________

Date of contact: __________________________________________________________

For More Information

This is one of six publications in a series on caregiving and aging. The other publications in this series are:

FCS2257: Long-Term Care: Places to Call Home (

FCS2259: Puzzled by Your Care Receiver's Refusal of Services? (

FCS2260: Balancing Work and Caregiving: Tips for Employees (

FCS2261: Balancing Work and Caregiving: A Guide for Employers (

FCS2262: Final Wishes: End-of-Life Decisions (



This document is FCS2258, one of a series of the Family, Youth and Community Sciences Department, UF/IFAS Extension. Original publication date November 2006. Revised August 2012. Reviewed December 2015. Visit the EDIS website at


Martie Gillen, assistant professor and Family and Consumer Economics for Older Adults specialist; and Carolyn S. Wilken, emeritus associate professor, Department of Family, Youth and Community Sciences; UF/IFAS Extension, Gainesville, FL 32611. Appreciation is given to Donna Peacock, Extension agent, UF/IFAS Extension Hernando County and Jennifer A. Wells, regional Extension agent, Auburn University, for suggestions and comments.

The Institute of Food and Agricultural Sciences (IFAS) is an Equal Opportunity Institution authorized to provide research, educational information and other services only to individuals and institutions that function with non-discrimination with respect to race, creed, color, religion, age, disability, sex, sexual orientation, marital status, national origin, political opinions or affiliations. For more information on obtaining other UF/IFAS Extension publications, contact your county's UF/IFAS Extension office.

U.S. Department of Agriculture, UF/IFAS Extension Service, University of Florida, IFAS, Florida A & M University Cooperative Extension Program, and Boards of County Commissioners Cooperating. Nick T. Place, dean for UF/IFAS Extension.