LEAVE OF ABSENCE (LOA) RETURN FORM

This form must be completed by the designated family member, guardian, or caregiver upon the resident's return from a home visit. The information provided helps our clinical team ensure continuity of care and monitor any behavioral or medical changes.

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1. Resident & Caregiver Information

• Resident Full Name: ________________________________________

• Departure Date/Time: __________________ 

Return Date/Time: __________________

• Caregiver/Family Member Name:

• ________________________________________

• Relationship to Resident: _______________ 

Contact Number: ____________

2. Medication Compliance & Management

• Were all prescribed medications administered exactly as scheduled?

o Yes

o No (If no, please list missed doses and reasons below)

o____________________________________________________________

o____________________________________________________________

• Were any new medications, over-the-counter drugs, or supplements given?

o Yes (Please specify below)

o No

o____________________________________________________________

• Remaining Medication Return Check:

o All unused medications returned? [ ] Yes [ ] No

3. Behavioral & Emotional Observations

Please rate and comment on the resident's general presentation during the leave:

• Overall Mood: [ ] Stable [ ] Elevated/Anxious [ ] Depressed/Withdrawn [ ] Fluctuating

• Sleep Patterns: [ ] Normal/Restful [ ] Insomnia/Difficulty sleeping [ ] Excessive sleeping

• Appetite/Fluid Intake: [ ] Good/Normal [ ] Poor/Refused food [ ] Excessive

• Did the resident exhibit any of the following? (Check all that apply):

o Agitation, irritability, or verbal aggression

o Physical aggression or property damage

o Confusion, disorientation, or forgetfulness

o Hallucinations or delusional statements

o Expressed thoughts of self-harm or suicide (If checked, notify staff immediately)

o None of the above

• Please briefly describe the resident’s activities and interactions during the leave:

_________________________________________________________________

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4. Physical Health & Incidents

• Did any physical health issues, injuries, or falls occur during the leave?

o Yes (Please describe below)

o No

o ____________________________________________________________

• Was there any known or suspected use of alcohol, illicit substances, or misused prescription medication?

o Yes (Please describe details to assist with clinical care)

o No

o ____________________________________________________________

5. Family Feedback & Clinical Notes

• Are there any specific concerns or changes you want the care team to follow up on?

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