Responsibilities: Conduct thorough psycho-social assessments and develop intervention plans for patients and families. Counsel and advocate on behalf of patients facing issues including but not limited to domestic violence, protective and ongoing services for special needs children and adults, guardianship, unplanned pregnancies, paternity issues, mental health or AODA. Collaborate internally as part of an interdisciplinary team of Providers, Nurses, Behavioral Health Providers, Health Educators and Case Managers to stabilize crises, improve patient functioning, link client to services and coordinate with external community resources. Establish, cultivate, and maintain a referral network of local agencies and link clients to resources as appropriate. Identify service-gaps and research options to assist patients. Maintain accurate and timely documentation in patient charts and submit statistical reports as requested. Participate as an active team member of the Social Services Department at staff meetings, in-service training and workshops, department problem solving exercises and providing support to coworkers. Actively provide feedback to leadership for quality improvement of workflows and processes. Represent the clinic in meetings, conferences and coalitions and actively advocate to end the root causes of poverty, mental health, housing, and health care access.