Social/developmental History Form
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3Social/Developmental History Form
This form was completed by:
__
Date:
SOCIAL HISTORY
Child’s Name
Address
Zip
Child’s Sex (circle) Male Female
Date of Birth
Race
Mother’s Cell
Dad’s Cell
Home Phone
Child’s School
Grade
Teacher
Parent’s Name
Age Range
Occupation
Work Phone Working Hrs. Education
Child Lives with:
Natural Mother
Natural Father
Step-Mother
Step-Father
Foster Family
Legal Guardian(s):
Was the child adopted?
Yes
No
If yes, at what age
Family history of learning or mental health difficulties experienced by child’s parents or siblings? Explain:
Please list all biological siblings (full, half and step) of this student:
Name
Age
Relationship to child Special Education?
Place of residence
Please list all other adults/or children living in the household with the child:
Name
Age
Relationship to child
Describe any significant disruptions the child may have experienced within the past year:
Divorce/Separation of parents
Parent re-married
Moving
Death of pet
Changed Schools
Friend moved away
Illness in family (explain)
Parent lost job or financial
Death (explain)
condition changed
Family member/child in trouble with the law (explain)
Child a victim of abuse or violence (explain)
Other:
What is the approximate number of hours of sleep the child gets per weeknight, on average?
Specific sleeping problems?
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