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MONTHLY SUPPORT GROUP MEETING REPORT
This report is to be completed by the facilitator and mailed/faxed to Alzheimer’s Arkansas
immediately after each meeting. It helps us develop, coordinate and assist all other
support group activities.
Support Group Name: _______________________________________________________________________
Meeting Date: _____________________________________ Meeting Time: From __________ to __________
Meeting Place: ____________________________________________ County: __________________________
Facilitator: ___________________________________ Co-Facilitator: ________________________________
Support Group Attendance: Number attending this meeting: ______ Number attending for first time: ______
_______ Please estimate the number of hours spent in connection with this support group, including
preparation, group time, and follow up. We need to track your volunteer hours as matches for federal grants
that we have.
What kinds of things did the group discuss?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did you have a guest speaker? Subject/Topic: ___________________________________________________
Name: ____________________________________________________________________________________
Title: ________________________________________________ Telephone: ___________________________
Address: __________________________________________________________________________________
Street Number, Name City, State, Zip
Do you recommend speaker to other support groups? ______ Yes ______ No
How can we help you? Tell us how Alzheimer’s Arkansas can improve its services to you and to the
participants of your group:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Person Completing Report: _______________________________________ Date: _______________________
Alzheimer’s Arkansas Programs and Services
201 Markham Center Drive ● Little Rock, AR 72205
501-224-0021 or 800-689-6090 ● Fax: 501-227-6303 ● www.alzark.org