Psychosocial History and Admission Assessment

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

Consent, Privacy, and Submission Notice

• Submission notice
  This assessment supports care planning, discharge planning, and social services documentation. Information collected may be shared with the care team as needed for treatment, operations, and coordination of care.
• Consent to collect and use information for care coordination
  I understand the information provided will be used for social services assessment, care planning, and coordination with the care team.
• Permission to contact family, caregiver, or other collateral contacts
  Check this only if the resident or legal representative authorizes contact with family members, caregivers, or other support persons.
• Preferred contact method
  Use only if follow-up contact is needed.

Resident and Admission Details

• Resident full name
• Date of birth
  Collect only if needed to match the resident record.
• Admission date
• Admitting location
• Primary language
  Include interpreter needs if applicable.
• Interpreter needed

Living Situation and Household Support

• Prior living situation
• Household members
  List the people who lived with the resident before admission, if relevant.
• Primary support person
  Enter the name or role of the primary support person if the resident authorizes disclosure.
• Support availability

Family System and Caregiver Network

• Overall family relationship quality
• Is a caregiver identified?
• Caregiver capacity concerns
• Family and caregiver notes
  Document relevant observations about the family system, support network, and any care coordination considerations.

Psychosocial Status, Mood, and Coping

• Current mood
• Mood change since admission
• Typical coping style
• Recent stressors
  Include only information relevant to psychosocial assessment and care planning.
• Behavioral health support needed
  Check if referral or follow-up for counseling, psychiatry, or behavioral health coordination may be needed.

Substance Use and Safety History

• Substance use history
• Substance use details
  Document only what is necessary for safe care coordination, such as substance type, current status, and any treatment supports.
• Safety concerns
• Safety notes
  Include brief, objective notes relevant to the care team and audit trail.

Goals, Preferences, and Initial Social Work Plan

• Resident goals
  What does the resident want to achieve during this stay or placement?
• Preferred supports
• Initial social work plan
  Summarize the immediate follow-up actions, referrals, and coordination steps.