Clemens Health | Weekly support-map 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.

Day and time
Which proposed or existing block are you reviewing? Repeat this sheet for other blocks.
Your notes: ________________________________________

Purpose
What activity or need is this block intended to address?
Your notes: ________________________________________

Service and contact
Which service/provider is responsible, and who coordinates it?
Your notes: ________________________________________

Status and questions
Is it requested, under review or confirmed? Are there overlaps to resolve?
Your notes: ________________________________________

Transition
What happens before and after this block, and who communicates changes?
Your notes: ________________________________________

Illustrative example
A daytime activity runs later than expected and overlaps with a proposed home-support visit. The map identifies the timing question and the two responsible contacts. It does not assume either service can be billed or delivered as originally proposed.

Next step
Ask the case manager to review service and overlap questions, then ask providers to confirm their actual staffed blocks. Share the agreed version with the person in a usable format.

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.