Clemens Health | Assessment conversation preparation
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.

What matters
Which routines, relationships or activities does the person want to maintain or change?
Your notes: ________________________________________

Current help
Who helps now, with what, and what limits or changes need explaining?
Your notes: ________________________________________

Everyday examples
What happens on a typical day and on a more difficult day?
Your notes: ________________________________________

Participation needs
Who does the person want involved, and what communication support should be requested?
Your notes: ________________________________________

Follow-up questions
Who explains the next step and how can the person raise remaining questions?
Your notes: ________________________________________

Illustrative example
A person manages an activity when their sibling is available, but the sibling’s work schedule is changing. The notes explain both what is currently working and why the arrangement may no longer be reliable. They do not assume the change automatically qualifies the person for a service.

Next step
Use the state contact directory to reach the appropriate county or tribal agency. Ask what information is useful for its process and how the person can participate comfortably.

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.