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Run: Psychosocial History and Admission Assessment

Psychosocial History and Admission Assessment template for skilled nursing intake, capturing family support, coping, housing stability, and social work needs...

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Consent, Privacy, and Submission Notice

Consent to collect and use this information for admission and care planning (required)

Required to proceed. This supports care coordination and social services documentation.

Yes No N/A

Who is completing this form? (required)

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 (required)

Medical record number

Use only if needed for internal identification.

Admission date (required)

Admission source (required)

Primary reason for admission (required)

Living Situation and Household Support

Current living situation (required)

Any housing stability concerns? (required)

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? (required)

Primary caregiver relationship

What tasks does the caregiver or family support?

Family involvement in care decisions (required)

Any family conflict, stress, or communication concerns affecting care? (required)

Describe the concern

Psychosocial History and Coping

Current emotional status (required)

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? (required)

Describe the loss or major life change

Needs, Referrals, and Initial Social Work Plan

Immediate needs identified (required)

Referrals needed

Any risk or safety concerns requiring follow-up? (required)

Describe the concern

Initial social work plan

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Email (required)

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