Clemens Health | Provider referral service brief
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.

Request and purpose
Which service and support goal are being discussed, and why now?
Your notes: ________________________________________

Location and schedule
Where would support occur and which days or hours are proposed?
Your notes: ________________________________________

Confirmed information
What is authorized or otherwise confirmed, and by whom?
Your notes: ________________________________________

Person’s preferences
What communication, worker-fit or scheduling preferences affect the discussion?
Your notes: ________________________________________

Requested response
What exactly should the provider confirm or clarify next?
Your notes: ________________________________________

Illustrative example
A case manager sends a brief for IHS with training with the learning goal, general location and proposed afternoons. The brief clearly says schedule confirmation is pending and asks the provider to identify any information needed to assess fit.

Next step
Use the brief to prepare the referral, then send information through the provider’s agreed intake channel. Track the specific response requested rather than treating form submission as acceptance of the arrangement.

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.