Clemens Health | My service-language question sheet
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.

Term or phrase
What exact word, acronym or status did you hear or read?
Your notes: ________________________________________

Plain-language meaning
How did the responsible person explain it?
Your notes: ________________________________________

Decision it affects
What does the explanation mean for your current choice or next step?
Your notes: ________________________________________

What remains open
What has not yet been assessed, authorized or confirmed?
Your notes: ________________________________________

Clarifying contact
Who can answer the remaining question, and where is the current information?
Your notes: ________________________________________

Illustrative example
A family hears that a referral is “accepted.” They ask whether that means the information was received or a service start is confirmed. Their notes use the specific answer so other family members do not assume visits are scheduled.

Next step
Bring your unanswered terms to the case manager or provider. Ask for the current decision and next step in language the person can use.

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.