Clemens Health | Household task conversation 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.

Activity
What exactly needs doing, and whose routine is it part of?
Your notes: ________________________________________

Person’s role
What would they like to do, choose or continue managing?
Your notes: ________________________________________

Requested assistance
Is the question about help completing, participating in, or learning the task?
Your notes: ________________________________________

Household boundaries
Which shared spaces, belongings or preferences need agreement?
Your notes: ________________________________________

Service question
Who will confirm the appropriate service and what remains outside the arrangement?
Your notes: ________________________________________

Illustrative example
A family asks for “meal help.” On discussion, the person wants assistance following an existing shopping list, while the family also wants weekly deep cleaning. Those are recorded as separate requests for service review rather than bundled under one label.

Next step
Bring the task list to the case manager. Once the service is clarified, ask the provider to confirm the practical visit 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.