Psychosocial History and Admission Assessment

Social services admission assessment for documenting psychosocial history, family system, support network, coping, and service needs in a skilled nursing or similar care setting.

Consent, Privacy, and Submission Notice

• Consent to collect and use this information for admission and care planning
  Required to proceed. This supports care coordination and social services documentation.
• Who is completing this form?
• Authorized representative name
  Complete only if someone other than the patient/resident is submitting or providing information.
• Relationship to patient/resident
• Preferred contact method for follow-up

Patient and Admission Details

• Patient/resident name
• Medical record number
  Use only if needed for internal identification.
• Admission date
• Admission source
• Primary reason for admission

Living Situation and Household Support

• Current living situation
• Any housing stability concerns?
• Housing stability details
• Household members or key people in the home
  List only people relevant to care planning. Avoid unnecessary PII.

Family System and Caregiver Network

• Is there a primary caregiver?
• Primary caregiver relationship
• What tasks does the caregiver or family support?
• Family involvement in care decisions
• Any family conflict, stress, or communication concerns affecting care?
• Describe the concern

Psychosocial History and Coping

• Current emotional status
• Coping strategies that help
• Relevant behavioral health history
  Include only information needed for care planning. Do not include unnecessary detail.
• Recent loss or major life change affecting adjustment?
• Describe the loss or major life change

Needs, Referrals, and Initial Social Work Plan

• Immediate needs identified
• Referrals needed
• Any risk or safety concerns requiring follow-up?
• Describe the concern
• Initial social work plan