Social And Developmental History Language And Speech
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3South Bend Community School Corporation
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Special Education Services
Social And Developmental History
Language and Speech
Date sent home:________________ by:____________________________
(PARENT/GUARDIAN COMPLETES THIS SECTION)
Student’s Name: ______________________________School:____________________ DOB:_______________
Address:____________________________________________________________________________________
Male
____ Female____
Ethnic group:__________________________________________________
Name of person providing information: ____________________________________________________________
Relationship to student: ________________________________________________________________________
Family Information
Mother's name
Age_
Education _____________________________
Employer______________
Phone: Home________________ Cell:_____________________
Father's name
Age_
Education _____________________________
Employer______________
Phone: Home_________________ Cell:____________________
Marital status of parents ________________________________________________________________________
If parents are separated or divorced, how old was the child when the separation occurred? ___________________
Is child adopted?
Yes___
No___
If yes, at what age? ______________________________
Has the child been in foster care? ____yes ____no If yes, when? ______________________________________
with whom?__________________________________________________________________________________
List all people living in household
Name
Relationship to Child
Age
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Primary language spoken at home_________________________
Other languages spoken at home __________________________
Is there a history of speech and/or language problems in the family? Yes _____No ______
If yes, list family member(s) describe______________________________________________________________
___________________________________________________________________________________________
What conditions at home could be influencing your child's communication and achievement in school (i.e., marital
problems, conflicts, illness of family members)?
___________________________________________________________________________________________
___________________________________________________________________________________________
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8/11/10
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