Clemens Health | Assessment request and callback tracker
Updated 2026-10-05 | (651) 354-1196

Use one copy for the initial request. Add dated entries after each conversation; do not mark an appointment or service as confirmed based only on a voicemail.

Reason for calling
Describe two activities where support is needed.
Illustrative entry: Help keeping an afternoon routine and getting to a chosen community activity.
Your notes: ________________________________________

Receiving team
Record the agency, contact route and person who responded.
Illustrative entry: County assessment intake; name and callback route recorded privately.
Your notes: ________________________________________

Request status
State exactly what happened and when.
Illustrative entry: Intake conversation completed; appointment not yet scheduled.
Your notes: ________________________________________

Participation needs
What does the person want arranged for the conversation?
Illustrative entry: Person wants a sibling present and written questions in advance.
Your notes: ________________________________________

Next action
Name the owner and the agreed follow-up point.
Illustrative entry: Intake team to explain scheduling; family will check back as discussed.
Your notes: ________________________________________

Changed circumstances
What new information needs to reach the team?
Illustrative entry: Regular informal support will be unavailable next month.
Your notes: ________________________________________

Illustrative example
A daughter calls a provider asking for “waiver care” for her father. The provider can discuss its services but does not schedule his county assessment. She uses the DHS directory, reaches intake, and learns that the team needs a separate request. Her record changes from “called a provider” to “assessment intake completed, awaiting scheduling.” She keeps the provider's information for later and prepares two examples of the support her father wants. This avoids treating a useful provider conversation as a completed assessment step.

Next step
Find the appropriate assessment contact in the DHS directory, make the first request, and record the next owner before comparing provider start dates.

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.