Clemens Health | Housing and daily support request-routing sheet
Updated 2026-10-05 | (651) 354-1196

Use separate entries for housing and support. Record a referral to another resource as a next step, not as approval or an available home.

Immediate housing need
What housing problem needs an answer, and by when?
Illustrative entry: Current lease question needs a housing contact; no new apartment selected.
Your notes: ________________________________________

Daily support need
What activity at home requires assistance?
Illustrative entry: Keeping household correspondence organized.
Your notes: ________________________________________

Housing contact
Which current resource handles the housing question?
Illustrative entry: Relevant DHS-listed resource to be contacted; eligibility unknown.
Your notes: ________________________________________

Support contact
Who reviews the support service and plan?
Illustrative entry: Case manager to review the routine and appropriate service.
Your notes: ________________________________________

Dependency
What must be known before another action can proceed?
Illustrative entry: Provider needs the proposed address before checking travel and staffing.
Your notes: ________________________________________

Confirmed outcome
What did each contact actually confirm?
Illustrative entry: Information received only; neither housing nor service start approved.
Your notes: ________________________________________

Illustrative example
A person searches for housing support because their lease is ending and they struggle to organize household mail. Their family initially asks an IHS provider to find an apartment. The request sheet separates the housing search from the everyday organizational support. They use current housing resources for the first question and ask the case manager about the second. The provider discussion records the address as unknown and does not promise a start. Both needs stay visible without presenting IHS as a housing-placement service.

Next step
Identify the immediate housing pathway through current DHS resources and ask the planning team to review the separate daily-support request.

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.