S02 - Attachment Y Psychosocial Assessment.pdf

PROGRAM:

HPI:

Diagnoses:

Marital Status:

Contact Information:

1) Name:

Relationship:

Address: 9307

City, State, Zip:

Telephone Home:

Telephone Cell:

Telephone Work:

2) Name:

Relationship:

Address:

City, State, Zip:

Telephone Home:

Telephone Cell:

Telephone Work:

3) Veteran's contact information (home phone, cell phone, other pertinent info):

MILITARY AND SERVICE CONNECTION INFORMATION:

Branch of Service:

Dates of Service:

NO: POW

NO: Purple Heart

NO: Combat, Location:

Per HINQ obtained on:

ECONOMIC:

Total Monthly Income:

VA SC Comp:

NO: Receiving Aid and Attendance?

NO: Receiving Auto Allowance?

SSA:

Medicare:

Medi-Cal:

LEGAL:

Rated incompetent for VA purposes:

Has VA fiduciary?

Power of Attorney for Funds:

Has payee for Social Security funds:

Any known history of reports to APS/CPS?

Any known history of legal issues?

If yes, please specify:

Does Veteran have a Conservator?

ADVANCED DIRECTIVE

Veteran executed an Advanced Directive on

DPAHCs are:

Are treatment preferences listed?

EDUCATIONAL/VOCATIONAL HISTORY

Other:

Occupation:

Date of last Employment:

SOCIAL/ENVIRONMENTAL:

Veteran's previous living arrangements prior to admission:

Social Support System and Family History:

Veteran was born in:

Veteran grew up in:

Veteran's family of origin consisted of:

Social Support Systems:

PSYCHOSOCIAL LEVEL OF FUNCTIONING

Cognitive & Emotional:

Coping Skills:

Communication & Social Skills:

Chemical dependency (past & present):

History/Indicators of Elder or Dependent Abuse:

OTHER SIGNIFICANT INFORMATION:

ASSESSMENT:

PLAN FOR SOCIAL WORK:

Patient participated in assessment?

Family/Caregiver participated in assessment?

Source of information: CPRS, HINQ, OTHER: in-person interview

PLAN/INTERVENTION: