Clemens Health | Roommate support choice discussion record
Updated 2026-10-05 | (651) 354-1196

Use a separate copy for each person, then compare only the information they agree to share. Ask the case manager to review proposed service arrangements.

Individual priority
What activity does this person want support with?
Illustrative entry: A weekly grocery trip and a private money-planning conversation.
Your notes: ________________________________________

Interest in sharing
Which activity, if any, do they want to share?
Illustrative entry: Interested in shopping together; not in sharing budgeting discussions.
Your notes: ________________________________________

Different preferences
What happens if the roommates want different things?
Illustrative entry: Discuss transport and staffing if one person wants to leave early.
Your notes: ________________________________________

Privacy boundary
Which information and spaces remain private?
Illustrative entry: Individual support records and bedroom routines.
Your notes: ________________________________________

Review question
What must the case manager or provider resolve?
Illustrative entry: Whether the proposed shared activity meets both people's needs.
Your notes: ________________________________________

Change route
How can the person request a different arrangement?
Illustrative entry: Named coordination contact and a private way to give feedback.
Your notes: ________________________________________

Illustrative example
Two roommates like visiting the same store. One wants to practice choosing ingredients; the other wants assistance following a familiar shopping list. They agree that going together sounds useful, but one prefers a short visit and the other likes browsing. The team records both preferences and asks how the proposed staffing would handle different return times. Their private planning conversations remain separate. The shared interest becomes a question to evaluate, not evidence that all support should be combined.

Next step
Ask each person about their preferences separately, then bring any proposed shared activity to the case manager and provider for review.

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.