FAMILY-SUPPORT CONVERSATION NOTES
Use with a hospital social worker, care coordinator or treatment-team member.
Source guide: https://yenra.com/eva-longoria/
Updated October 9, 2026

Start with the practical need that matters most this week. Complete what you
know, then fill in the referral and follow-up details with the care team.
Keep completed notes private. This is a personal worksheet, not an online
application, eligibility decision or promise of assistance.

Date of conversation:
Person and role helping us:
Preferred language, contact method and accessibility arrangements:

1. What help would make the next appointment or week more manageable?
   (For example: travel, accommodation, school contact, or communication.)


2. When is it needed? Is the need one-time or repeated?
   Appointment dates or relevant time period:


3. What details affect the request?
   Treatment location, travel area, household circumstances to discuss:
   Share sensitive details only with the appropriate service.


4. Which program or person should we contact?
   Program name and verified contact:
   Who makes the referral:
   Information or documents required:
   Eligibility or cost questions still to clarify:


5. What happens next?
   Person responsible for the next action:
   Expected response date:
   How and when to follow up:


6. If that program cannot help, what is the next route?
   Alternative contact or service:
   Plan while a request is pending:


Before leaving: read back the agreed next action, who will take it and when.
A request or referral does not guarantee a service or accommodation place.
Ask the care team for current local options and individual instructions.