Clemens Health | Overnight service discussion 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 overnight need
What assistance is being requested and when does it arise?
Your notes: ________________________________________

Caregiver’s need
What relief or time away is being sought, and by whom?
Your notes: ________________________________________

Setting
Where would support take place, and what needs checking about that setting?
Your notes: ________________________________________

Existing services
What support is already in place that the case manager should review?
Your notes: ________________________________________

Next determination
Who will clarify the service option before a provider confirms staffing?
Your notes: ________________________________________

Illustrative example
A family asks for help on several nights while the primary caregiver is away. They also describe ongoing nighttime assistance needs. The case manager reviews both questions instead of assuming the timing alone determines the service.

Next step
Bring the two-part description to the case manager. Then ask the relevant provider about the specific dates, setting and arrangement that have been reviewed.

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.