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Winston-Salem/

Forsyth County Schools

/ Brief Social Developmental History (Confidential)
Date: ______
Careful professional consideration should be given in deciding which Psychosocial Developmental History instrument is appropriate for a student. The level of intensity, rather than suspected service area, should be your guide. For instance, children that exhibit a significant degree of autism, mental health issues, serious home or environmental concerns, and/or clear mental retardation may all warrant the more comprehensive History. Children who exhibit simple articulation issues or clear academic issues in reading or math without social co-morbid factors could be evaluated using the Brief History form.
Student: / Interviewer and Title:
School: / Grade: / Person Providing Information:
Student Number: / Relationship to Student:
Address:
Phone: (H) (C) (W) / DOB: Age: / M / F

Reason for referral:

Student Resides With: Mother Father
Both Parents Guardian (relationship: ______) / Parental Status: Single Parent Married Separated Divorced
Mother Remarried Father Remarried Mother Deceased Father Deceased
Legal Custodian: / Frequency of visitation with non-custodial parent:

List all previous schools, including preschools: ______

______

Brothers and Sisters:

Name Age School/Grade Strengths & Difficulties

1.______

2.______

3.______

4.______

Child’s Developmental History

Were there any problems during pregnancy with this child? Yes No Birth weight: ______Full term? Yes No

If problems, please explain: ______

Were any of the following problems significantly present during the first few years of life?

Was your child difficult to comfort? Yes NoWas your child excessively irritable? Yes No

Did your child have a consistent sleep pattern? Yes NoWas nursing/feeding a problem? Yes No

Developmental milestones (see below):Compared to children the same age, does your child:

Early Typical* Late

Sitting

Crawling

Walking

First words

Using sentences/phrases

Toilet training

More Same Less

Have good motor skills?

Appear clumsy?

Appear active?

Pay attention?

Adapt to transition and change?

Engage in social activities?

*Typical age ranges: ability to sit with, and then without, support – 6-8 months; ability to crawl – 9-12 months; ability to walk – 12-17 months; use of first words (excepting caregiver terms such as “mama” and “dada,” which can come earlier)– 15-18 months; use of phrases and simple sentences – 22-24 months; potty training – 24-36 months (can vary due to a variety of factors). Source: American Association of Pediatrics (AAP) “Developmental Milestones.”

Frequency of accidents or soiling since toilet trained? ______

What, if any, current concerns do you have about your child’s speech? ______

______

What is your child’s current basic mood? ______

Child’s Medical History

Diagnosed with any of the following?
Asthma
Headaches
Sickle Cell
Allergies / Chicken Pox
Vision Problems
Ear Infections
Hearing Loss / Diabetes
Weight issues
Heart Condition
Stomachaches / Fever (+103)
Brain injury
Seizures
Cancer/Leukemia / Chronic illness
Substance Abuse
Mental health diagnosis
Other: ______

If checked, please explain: ______

______

Medications: ______

Hospitalizations, Surgery and Accidents: ______

______

Explain current family stressors: ______

______

Psychological evaluations (when and by whom?): ______

2/2008 SoWk