Spiritual Care Needs Assessment

Assessment form for chaplaincy or social work to document a resident's spiritual background, faith tradition, coping supports, care preferences, and requested spiritual services in a nursing home or long-term care setting.

Submission Notice and Consent

• Purpose of this assessment
• Consent to document spiritual and faith-related information
• Limit sharing of this information

Resident and Encounter Details

• Resident name
• Resident ID
  Use only if your facility uses an internal resident identifier.
• Assessment date
• Assessor name
• Assessor role
• Reason for assessment

Faith Tradition and Spiritual Identity

• Faith tradition or spiritual identity
  Examples: Catholic, Baptist, Jewish, Muslim, Buddhist, Hindu, Christian, spiritual but not religious, or other.
• How important is faith or spirituality in daily life?
• Spiritual or religious practices the resident wants to continue
• Details about preferred practices

Meaning, Coping, and Support

• What gives the resident meaning, hope, or comfort?
• Spiritual or emotional supports that help during stress
• Additional details about coping supports

Preferences, Accommodations, and Requests

• Preferred frequency of spiritual care visits
• Preferred times for visits
• Requested accommodations
• Details about requested accommodations
• Requested spiritual services

Care Plan Notes and Follow-up

• Care plan summary
• Referrals made
• Follow-up date
• Additional notes
  Document only information relevant to spiritual care and care coordination.