Clemens Health | First-conversation agenda
Updated 2026-10-05 | (651) 354-1196

Download this editable worksheet, add your notes, and bring it to the relevant planning conversation. Leave unknown details blank and identify who can confirm them.

Top priority
What does the person most want help understanding or changing?
Your notes: ________________________________________

Current situation
What support exists now and what prompted this conversation?
Your notes: ________________________________________

Questions about options
Which service terms or possible arrangements need explanation?
Your notes: ________________________________________

Roles and decisions
Who handles assessment, authorization, provider fit and scheduling?
Your notes: ________________________________________

Agreed follow-up
What is the next action, who owns it, and how will you hear the result?
Your notes: ________________________________________

Illustrative example
A family assumes that identifying an IHS provider means visits can start. At the meeting they ask which planning and staffing steps remain. Their notes list those decisions separately instead of treating the referral as a confirmed schedule.

Next step
Take the short agenda to the conversation and keep the agreed follow-up notes. Use a provider inquiry separately when you are ready to discuss service fit and availability.

This is an optional discussion worksheet, not an official assessment, authorization, service plan, or emergency plan. Keep completed copies private and share through an agreed channel.