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 664-5066. 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 ____
Native Hawaiian or Other Pacific Islander____
Black or African American ____
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:_____________Email:_______________ Occupation & Employer_______________________________________________________________
Parent/Guardian #2 Name:______________________________________DOB: _________________ Home Address: ____________________________________________________________________ Phone#-Home:______________Work: _______________ Cell:______________Email_____________ Occupation & Employer_______________________________________________________________ Rev. 8/14
4 Fairchild Square, Clifton Park, New York 12065
(518) 664-5066
Fax (518) 664-5728
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: ________________________________________________________________________ ________________________________________________________________________________
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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
_________________________
______________________
______________________
_________________________
______________________
______________________
_________________________
______________________
______________________
_________________________
_______________________
______________________
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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 664-5728 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 664-5066.
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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:_________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
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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:______________________________ ________________________________________________________________________________ ________________________________________________________________________________
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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. ________________________________________________________________________________ ________________________________________________________________________________
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