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Run: Psychosocial History and Admission Assessment

Psychosocial History and Admission Assessment template for documenting a resident’s support system, mood, coping, substance history, and initial social work ...

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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 (required)

I understand the information provided will be used for social services assessment, care planning, and coordination with the care team.

Yes No N/A

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.

Yes No N/A

Preferred contact method

Use only if follow-up contact is needed.

Resident and Admission Details

Resident full name (required)

Date of birth

Collect only if needed to match the resident record.

Admission date (required)

Admitting location

Primary language

Include interpreter needs if applicable.

Interpreter needed

Yes No N/A

Living Situation and Household Support

Prior living situation (required)

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? (required)

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 (required)

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.

Yes No N/A

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 (required)

Summarize the immediate follow-up actions, referrals, and coordination steps.

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