203 West Hillside Road

NapervilleCommunityUnitSchool District 203

203 West Hillside Road

Naperville, IL60540

SOCIAL DEVELOPMENT STUDY
Student Name: / Date:
SOCIAL HISTORY
FAMILY COMPOSITION
Parent’s Name: / Age:
No. of Marriages: / Marital Status:
Occupation: / Employer:
Working Hours: / Educational Background:
Step Parent: / Age:
No. of Marriages: / Marital Status:
Occupation: / Employer:
Working Hours: / Educational Background:
Parent's Name: / Age:
No. of Marriages: / Marital Status:
Occupation: / Employer:
Working Hours: / Educational Background:
Step Parent: / Age:
No. of Marriages: / Marital Status:
Occupation: / Employer:
Working Hours: / Educational Background:
Sibling's Name: / Age: / At Home:
Sibling's Name: / Age: / At Home:
Sibling's Name: / Age: / At Home:
Sibling's Name: / Age: / At Home:
Others in home:
Significant family changes:

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Student Name: / Date:
RELATIONSHIP PATTERNS
Parent:
Parent:
Step Parent(s) or
Significant Others:
Adults:
Siblings:
Peers (consideration for feelings of others, play preference group/alone/dating):
Parents response to peers:
SCHOOL HISTORY (since previous evaluation)
Schools attended (name, location, dates and grade):
Educational Support (tutoring/homework assistance):
Has the child been retained?
Student's attitude toward school:
Parent's view of student's school experience:
School disciplinary status:
Academic standing/progress:
Previous Psychological Educational Evaluation / Date / Outcome
Student Name: / Date
SIGNIFICANT EVENT
Death (Family/Friend / Economic Status Change / Police Contact
Divorce/Separation(Include dates) / Family Structure Change / Residency Change (frequency)
Domestic Violence / Illness of Family Member / Other
(physical or emotional)
Comments:
BEHAVIOR/EMOTIONAL REACTIONS
Adapt to change/transition / Expressed Fears / Rocking/Head Banging
Crying Episodes/Tantrums / Habits/Repetitive Behaviors / Response to Illness/Injury/Stress
Depressive Symptoms / Hyperactive/Impulsive / Separation Anxiety
Drug/Alcohol Abuse / Lack of Eye Contact / Tuning Out
Sleep disturbances / Masturbation / Other
Comments:
Student Name: / Date:
PERSONAL HISTORY
History of Counseling:
Typical Home Behavior (daily routine, responsibilities, level of cooperation):
Methods of Discipline (who administers, parental agreement, student response, effectiveness/outcome, potential reinforcers/motivators):
Driver's License: / Employment:
Volunteer Activities/Sports:
Hobbies/Interests:
Parents Perception of Student:
Strengths:
Weaknesses:
Expectations/Aspirations:
Student Name: / Date:
ADAPTIVE BEHAVIOR
Assessment Tool Used: / Date:
Summary Results:
ADDITIONAL COMMENTS (If needed):
Interviewer: / Position:
Person Interviewed: / Relationship to Child:
Date of Interview:

Social Development Study.doc

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