Clemens Health | Referral follow-up log
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.

Referral reference
When and through which agreed channel was the request sent?
Your notes: ________________________________________

Last confirmed fact
Was receipt, review, missing information, fit or staffing actually confirmed?
Your notes: ________________________________________

Current question
What single decision or missing detail is holding up the next step?
Your notes: ________________________________________

Owner and follow-up
Who is addressing it, and what follow-up point was agreed?
Your notes: ________________________________________

Update to the person
What can be communicated accurately, and what remains uncertain?
Your notes: ________________________________________

Illustrative example
A coordinator receives a referral receipt but no staffing decision. The follow-up asks whether the requested evenings have been reviewed and names the original submission date. The update to the family says review is pending, not that a worker has been assigned.

Next step
Use the provider’s agreed follow-up route. For Clemens Health, call (651) 354-1196 to clarify a referral’s next step rather than assuming a second form submission is needed.

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.