Office of Student Support Services Patricia Clark, Chief Ombuds/Student Support Services Officer

SCSD SOCIAL HISTORY GUIDE(This form is used to gather information/notes to be used to create the narrative social history)

School ID# ________________________ Initial: _______ Updated: _______

Name: _____________________________________ School: __________________________

DOB: _____________________ Age: _________ M: _____ F: _____ Date of Report: _________________

Address: __________________________________________________________________________________

Source of information: Mother____ Father____ Legal Guardian____ Other__________________________

Student lives with: ________________________________ Custody: _________________________________

MOTHER:

Age:

Home Telephone:

Cell: Work:Highest Level of Education: Address:

FATHER:

Age:

Home Telephone:

Cell: Work:Highest Level of Education: Address:

LEGAL GUARDIAN:

Age:

Home Telephone:

Cell: Work:Address:

SYRACUSE CITY SCHOOL DISTRICT

Siblings

Name AgeLiving in Home

School Grade Special Ed

Language spoken by child in the home:

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Other language:

______________________________________________________________________________

Interpreter needed? Yes ____ No ____

What are your child’s strengths/interests?

______________________________________________________________________________

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Child’s favorite activities/hobbies:

1. ______________________________________________________________________

______________________________________________________________________

2. ______________________________________________________________________

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3. ______________________________________________________________________

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REFERRAL INFORMATION

Please describe your concerns regarding your child’s development:

______________________________________________________________________________

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How long has this been a concern for you?

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What helps the problem?

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What makes things worse? _____________________________________________________________________________________

What discipline techniques are effective/ineffective at home?

______________________________________________________________________________

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Does your child exhibit any behaviors that you would like to see less of and/or do you have any

concerns about social/emotional/behaviors?

______________________________________________________________________________

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SOCIAL AND BEHAVIOR CHECKLIST

BEHAVIORCOMMENTS

(yes/no, explain)BEHAVIOR

COMMENTS

(yes, no, explain)

Difficulty with speech sounds and/or using language

Are there any safety concerns? (Example: Climbing, impulse control, playing w/dangerous items)

Fidgets/Attention Span Problems

Special fears/habits/mannerisms (Example: bangs head, rocks, puts things in mouth) Please describe.

Fine motor concerns (example: hold pencil, zipper/button)

Gross motor concerns (example: safe on stairs)

How does your child play? (likes to play independently/with others) Friendships and Peer Relationships

Sleeping habits (sleeps through night? Naps?)

Gets along with siblings/cooperative.

Tantrums Why? When? How often? Can they calm themselves?

Chores child does or helps around house. Sad/Depressed often?

Is shy or timid, outgoing or reserved?

What activity holds their interest the longest? Do you have attention concerns?

Stubborn Fire setting history

Gets easily frustrated Is impulsive

Angry oftenTemper rating: even/quickMild/strong

Anxious/worried

Moody/changes mood often

History of mental health treatment(CPEP, suicidal/homicidal Ideation)

Grief/Loss (history of) General Trauma

Is there anything else that you would like us to know about your child?

______________________________________________________________________________

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______________________________________________________________________________

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Adaptive or other Behavior rating scale:

______________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

Previous evaluations? Yes ____ No ____

Where: _______________________________________________ Date: __________________

Previous/Current services:

_____________________________________________________________________________

How often does the other parent see this child? _____________________________________________________________________________

Other important people in life: _____________________________________________________________________________

Family strengths/activities: _____________________________________________________________________________

Family Stressors: _____________________________________________________________________________

Any family history of substance abuse, alcohol abuse or mental health issues?

________________________________________________________________________

______________________________________________________________________________

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BIRTH/DEVELOPMENTAL /HEALTH HISTORY

Where was the child born? ____________________________________ Birth weight: ________

Premature? Yes ____ No ____ If yes, how many weeks? __________

Cesarean section? Yes ____ No ____ If yes, why?

______________________________________________________________________________

Any complications during pregnancy, delivery or birth? Yes ____ No____ If yes, please

explain:

______________________________________________________________________________

______________________________________________________________________________

Medication during pregnancy? Yes ____ No ____ If yes, what kind?_____________________

______________________________________________________________________________

Any use of alcohol, drugs or tobacco during pregnancy? Yes ____ No____ If yes, please

specify:

______________________________________________________________________________

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Did your baby pass the newborn hearing screening? Yes____ No____ Ear Infections? Yes____

No____

Has your child been screened for hearing? Yes ____ No ____ If yes,

results:________________________________________________________________________

Has your child been screened for vision? Yes ____ No _____ If yes, results:

______________________________________________________________________________

Have you or any doctor expressed any growth or developmental concerns regarding your child?

Yes___ No___

If yes, have/are they being monitored for this concern?

______________________________________________________________________________

Current medical provider/medications:

______________________________________________________________________________

Other current health concerns or needs:

______________________________________________________________________________

DEVELOPMENTAL MILESTONES

BEHAVIOR AGE BEHAVIOR AGE

Rolled over Put two words together

Sat alone Dressed self

Crawled Toilet trained

Walked alone Fed self with fingers

Babbled/cooed Fed self with spoon

Spoke first word Slept through the night

Tricycle Bicycle

ACADEMIC HISTORY

Previous schools attended Start/End Date

Daycare/Other (stayed w/family member) Dates

Likes School?

_______________________________________________________________________

Attendance Patterns

_____________________________________________________________________________

Parent’s view of how child does: Reading __________ Math __________ other subjects

_____________________________________________________________________________

Parent’s concerns about learning

_____________________________________________________________________________

Others in family with academic struggles

_____________________________________________________________________________

What resources do you think will help your child?

_____________________________________________________________________________

COMMUNITY AGENCY SERVICES (Counseling, After School Program, Sports, Church, CPS, PPS)

Agency/Telephone Contact Person Services

Statement of how this information was gathered: phone interview/office interview, with

whom, records review, etc. Ex: The information included in this Social History Report was

gathered during an office visit interview with Ms. Jones. Other information was also gathered

from school records.

______________________________________________________________________________

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Name of Social Worker:___________________________________________________________

Signature:_____________________________________________ Date:____________________

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