Clemens Health | Skill-goal conversation worksheet
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.

Person’s priority
What do they want to do, in their own words?
Your notes: ________________________________________

Starting point
Which parts already work, and what support or tools are used?
Your notes: ________________________________________

Learning focus
Which specific part would they like to practice?
Your notes: ________________________________________

Useful progress
What change would the person notice and value?
Your notes: ________________________________________

Review agreement
Who will discuss progress with the person, using which observations?
Your notes: ________________________________________

Illustrative example
“Learn to cook” becomes “I want to choose one lunch and use a shopping checklist to prepare for it.” The team discusses which part needs teaching and how the person wants practice to feel. This is a proposed goal for review, not an approved service task.

Next step
Bring the goal to your case manager and IHS provider. Once the learning focus is agreed, use a separate practice-plan worksheet to discuss how it could work.

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.