Confidential Student History

The school social worker may call you if they have questions as they review the form. The information in this form is considered confidential.

Child’s Name:

(first) (middle) (last)

Date of Birth: Current School:

Person completing this form:

Part 1. Identifying Information

What are some of your child’s strengths (things he/she is good at, qualities that make him/her special):

What is your primary concern about your child?

What are your child’s favorite interests/ activities/toys?

Part 2. Family History

Mother/Step Mother/Guardian’s Name:

Occupation

Home Phone Cell Work

Address

Father/Step Father/Guardian’s Name:

Occupation

Home Phone Cell Work

Address

Languages spoken in the home:
Child’s primary language:

Current family status:

Married Separated Divorced Widowed Living Together

Please list all persons living in the home with the child.

Name / Age / Relationship

Has any biologic family member had any of the following?

Concern / Family member/Description
Learning Disability
Speech/Language Problems
Attention Deficit Disorder(ADD)
Emotional Issues (depression, anxiety)
Autism
Developmental Delay
Drug/Alcohol Problems
Legal Issues
Domestic Violence
Abuse/Neglect/ Human Services Involvement
Homelessness
Other Health Concerns

Part 3. Pregnancy and Birth History

Please describe any concerns or problems during pregnancy (medical, stressful situations such as death or divorce):

When did prenatal care begin?

Yes / No
Was the baby born on time?
Was the baby born by Cesarean?
Were drugs or tobacco used during pregnancy?
Was alcohol used during pregnancy?
Were any medications taken during pregnancy?

Please describe any difficulties with labor and delivery?

How long did mother and child remain in the hospital?

Were any specialized treatments required at birth (oxygen, medications)?

Baby’s birth weight

Did the mother experience any postpartum depression or other emotional issues after birth?

Part 4. Infancy and Toddler Stage

Describe your child as an infant. Check all that apply.

Cuddly / Cried a lot
Active / Happy
Hard to soothe / Did not like to be held
Colicky / Difficulty sleeping
Easy baby / Inactive

At what age did your child meet these developmental milestones?

Sat alone / Babbled
Crawled / Said mama or dada
Walked alone / Said other single words
Toilet training / Used longer phrases

Were there any concerns that your child was not developing? Explain.

Was there ever any loss of skills? Explain.

Describe your child’s behavior as a toddler (ages 3-5). Check all that apply.

Thumb sucking / Tantrums
Distractible / Sleep difficulties
Angers easily / Staring spells
Rocking / Hand or finger flapping
Sensitivity to sound/light / Aggression
Head Banging / Moody
Sad / Anxious
Fearful / Obsessions
Sensitivity to touch / Eating difficulties
Nail biting / Breath holding
Prefers to play alone / Difficult to understand

Do you have any current concerns about your child’s development?

Part 5. Health History

Does your child/family have medical insurance? If not, may the social worker contact you to discuss options?

Who is your child’s primary care doctor?

Date of last visit?

Has your child been diagnosed with any medical condition or are they under the regular care of a doctor for a chronic health issue? Explain.

Is your child currently taking any medication or herbal supplements? Explain.

Please indicate if any of the following health issues have been present in the past or if they are currently an issue.

Concern / Current / Past
Frequent ear infections
Seizures
Hospitalizations
Head injury * please provide details below
Loss of consciousness
Vision problems
Hearing problems
Allergies
Skin problems
Sleeping problems
Asthma
Diabetes
Food allergies/sensitivities
Other health issues

* Please provide Head injury details (date, was medical attention sought?, etc) ______

Please explain any current health issues.

Part 6. School History (if applicable)

What are your child’s strengths and interests at school?

What are your child’s challenges at school?

Does your child like school?

What do you think your child needs to be more successful at school?

Any additional information you would like to share? ______

Part 7: Ethnicity and Race

Please complete the following two questions regarding your child’s race and ethnicity:

1.  Is your child Hispanic/Latino? (choose only one)

___ No, not Hispanic/Latino

___ Yes, Hispanic/Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

The above part of the question is about ethnicity, not race. No matter what you selected in question 1 above, please provide an answer to question 2 by marking one or more boxes below to indicate what you consider your child’s race to be.

1.  Which of the following groups describe the child’s race? (choose one or more)

___ American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

___ Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

___ Black or African American. A person having origins in any of the black racial groups of Africa.

___ Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

___ White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Signature of person completing this form Date