Social History Outline For Children
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3SOCIAL HISTORY OUTLINE FOR CHILDREN
Agency:
County of Residence:
Compiled by:
Date:
Child Information:
Name:
Date of Birth:
Current Address:
Place of Birth:
Previous Address:
Sex:
Race:
Grade in School:
Religion:
Name:
Telephone: (
)
Informants:
Address:
Comments: (Reliability etc.)
Responsible Person or
Name:
Telephone: (
)
Agency:
Address:
Guardian Ad Litem:
Presenting Problem. Nature of current problem. Examples. The situation and circumstances at onset.
How problem developed. How it recurs. Secondary problems. Efforts by the family and/or others to
cope/solve the problem. How successful? Previous diagnostic studies. Date of studies, location and
results.
Reason for Referral. Who assisted parents, guardian, or court to decide to request servcies?
Alternative plan to out of home care considered? Why/How was decision reached? What are the
parent’s/caregiver’s expectations of the service ? To what degree are they able/willing to participate in
the diagnosis/planning/treatment of the child? How does the child/youth feel about the referral? Has
the worker interviewed this child? If so, where/when/under what circumstances? Worker observation
and impressions of the child.
Family Information. Father. Full name, birth date, place of birth, ethnic background, present location,
education, occupation, physical description. What is the status of the father’s physical and mental
health? Comment on father’s family background, significant early childhood relationships and
experiences.
Mother. Full name, birth date, place of birth, ethnic background, present location, education,
occupation, physical description. What is the status of the mother’s physical and mental health?
Comment on mother’s family background, significant early childhood relationships and experiences.
Date of parents’ marriage. Have they been married previously? Give dates/information. If one/both
parents are deceased, give cause of death. What was effect on the child? Comment on relationship
between the parents. Do their religious affiliations/attitudes affect the child?
Siblings. List names, dates of birth, grade level in school, state of physical, emotional health. List with
whom they are currently living. Show history of foster home/residential/ institutional placements and
other pertinent information.
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