Common Summary Assessment Report Template
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4COMMON SUMMARY ASSESSMENT REPORT
Please complete all sections clearly in block capitals. Read guidance notes before completing
I confirm that the assessment process and purpose has been explained to me. I consent that information may be
shared as appropriate by relevant health and social care professionals in the processing of this application.
Signature ___________________________________________ Applicant/Specified Person Date ___________________
(Delete as appropriate)
:
1. SOURCE OF REFERRAL (PLEASE TICK)
Community Hospital
Acute Hospital
GP
Mental Health
Community
Nursing Home
Name of Referring Location: _____________________________ Date of Referral: _____________
2. PERSONAL DETAILS:
First Name: ______________________ Surname(s): ______________________ Preferred Name: ______________________
Current Address:
Home/Past Address (If relevant):
Tel No(s):
_________________________________
_________________________________
______________________________
_________________________________
_________________________________
Date of Birth (DD/MM/YYYY)
Medical Card No: ___________________
Hospital Number:___________________
______________________________
PPS No. : ________________________________________________________________________________________________________
3. PERSONAL CIRCUMSTANCES:
Marital Status:
Single
Married
Widowed
Separated
Divorced
Other
Living Circumstance:
Alone
With Spouse
With partner
With family
With carer
With Other
Describe Housing situation (See guidance document):
Who is the Principal Carer: _______________________________________________________________________________
What level of support do they provide?
(Please include contact details):
Assessment of Carerʼs needs completed?
Yes
No
(Please attach if available)
Identify any family members, neighbours, friends who provide support:
Contact Person/Specified Person/Care Rep: _______________________________________
Relationship to applicant?
(Contact details address/phone/mobile):
_______________________________________
__________________________
___________________________________________________________________________
GP: _________________________________________________
Contact Details: _________________________________
PHN &/or CMHN: ______________________________________
Contact Details Health Centre: _____________________
4. ALL APPLICANTS
have the right to self-determination and capacity to do so is assumed unless otherwise proven.
m m u u s s t t b b e e s s o o u u g g h h t t a a n n d d r r e e c c o o r r d d e e d d . .
His/her preference to stay at home or to be admitted to residential long-term care
Yes
No
Has the personʼs above preference been discussed with him/her?
If YES - brief outline of outcome
________________________________________________________________________________________________________
________________________________________________________________________________________________________
If No - Provide a reason and identify with whom it has been discussed & outline outcome
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
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