SOCIAL HISTORY FORM. Child s First Name: MI Last Name: Male/Female Date of Birth: Date of Evaluation: School District

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1 SOCIAL HISTORY FORM A social history is a required part of the evaluation process. Please complete this form to the best of your ability. If you have any questions regarding this form or the evaluation process please call Helping Hands School at Child s First Name: MI Last Name: Male/Female Date of Birth: Date of Evaluation: School District Form Completed by: Date Form Completed: Address: Racial/Ethnic Category: Hispanic/Latino If not of Hispanic origin, check one of the following: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Two or more races REASON FOR REFERRAL Why are you seeking an evaluation for your child? Who recommended this evaluation? Has your child had any previous evaluations? Yes No If yes, please list dates, evaluators and areas assessed: FAMILY INFORMATION Parent/Guardian #1 Name: DOB: Home Address: Phone#-Home: Work: Cell: Occupation & Employer Parent/Guardian #2 Name: DOB: Home Address: Phone#-Home: Work: Cell: Occupation & Employer Rev. 8/14 4 Fairchild Square, Clifton Park, New York (518) Fax (518)

2 Please list below all people living in the home with the child: Children or adults: Date of Birth Relationship to Child: Who cares for your child during the day? If your child is enrolled in a preschool program, please provide name, address and days/times attend: FAMILY HISTORY Do this child s parents, grandparents, siblings, or any close relatives have: Yes No If yes, relationship to child Hearing Loss Speech problems Seizure Disorder Genetic Disorders Birth Defects Attention Deficit Disorder Autism Spectrum Disorder Learning Disabilities Other, please specify: Are there any family members who have ever had problems similar to those of your child? If yes, please describe: 2

3 CHILD S BIRTH HISTORY Were there any complications during pregnancy with this child? If yes please explain: Were there any delivery complications with this child? (ex: Caesarean section, cord wrapped around neck, fetal distress)? If yes, please explain: Duration of Pregnancy weeks (40 weeks is full term) Birth Weight: Pounds Ounces Were there any post-delivery complications while the child was still in the hospital (jaundice, respiratory difficulties, fetal difficulties, NICU)? If yes, please explain: CHILD S MEDICAL HISTORY Child s Physician: Physician s Phone: Physicians address: Physician s Fax: How long has your child been in the care of this physician? Does your child see any other doctors or medical specialists? If so, please list below: Physician s Name Specialty Reason 3

4 Is there anything important we should know about your child s medical history (ex. surgeries, hospitalizations, injuries, allergies, disorders, serious illnesses)? Does your child have a history of ear infections? Yes No If yes, how frequent? Has your child ever had Pressure Equalization tubes inserted into his/her ears? Yes No If yes, date of insertion: Are they still in place? Has your child ever had a hearing evaluation? Yes No If yes, please list the date, location and results of the evaluation: Do you have concerns regarding your child s ability to hear? Yes No Do you have concerns regarding your child s vision? Yes No Is your child up to date with his/her immunizations? Yes No Does your child receive Medicaid? Yes No If yes # ********IMPORTANT NOTE******** A required component of this evaluation is a signed physical report from your child s doctor. If your child had a physical within the past year, a new physical is typically not necessary. Please submit the physical form attached to this packet to your child s doctor for completion. You can return it by either 1) Enclosing and returning it with the rest of our paper work in the enclosed envelope or 2) Your physician can fax the form to us at or 3) You can bring it with you at the time of this evaluation. Your child s evaluation is not considered complete by your school district until the physical form is provided. If you have any questions or need assistance please call us at ********************************** 4

5 EARLY DEVELOPMENTAL HISTORY Please complete this section to the best of your ability. If you can recall, please record the specific ages at which your child reached the following developmental milestones. If you cannot recall specific ages, please rate whether your child achieved them early, within average age limits or at a later than expected age. Age Early Average Late Held head up Responsive smile Rolled over Sat without support Crawled Pulled to standing Walked without assistance Babbled- played with sounds Spoke first true words besides mama & dada Said phrases (ex: more juice) Said sentences (ex: I want more juice ) Did your child receive services through the Early Intervention Program? Yes No If so, please indicate services and dates: 5

6 CURRENT DEVELOPMENT We recognize that children are referred to us at various ages and for different reasons. Please complete this section to the best of your ability. In what way does your child communicate his/her needs? (pointing, crying, gestures, single words, phrases, sentences, etc). Do family members and familiar people understand what your child says? What percentage of time is he/she understood? % Do unfamiliar people understand what your child says? What percentage of time is he/she understood? % Does your child appear to understand and follow directions as well as other children the same age? If not please explain: Does your child respond to and answer questions as expected? If not, please explain: Does your child turn to person speaking when his/her name is called? Please rate your child s motor abilities for the following skills: Above Expectations Age Appropriate Area of Concern Walking Running Jumping Climbing Coloring Cutting If you have concerns about your child s motor skills, please explain: 6

7 All children exhibit, to some degree, the kinds of behaviors listed below. Check those your child exhibits to an excessive degree when compared to other children of the same age. Provide comment or clarify if needed. Hyperactivity Hypoactivity (low activity level) Poor attention span Impulsivity Low frustration threshold Difficulty sleeping/eating/drinking Interrupts frequently Does not listen when spoken to Aggressive toward other children Please explain any concerns you have about your child s behavior: What games/activities/toys does your child enjoy? Please describe your child s personality (shy, outgoing, easy-going, moody, happy,.) Does your child seek to interact with other children? Enjoy the company of other children? Does your child play primarily with children of the same age?, younger? older? Please describe briefly any difficulties your child may have with peers: ADDITIONAL INFORMATION Please use this space to make any additional comments or information that will help us understand your child, your concerns or family needs. 7