Office of Student Support Services Patricia Clark, Chief Ombuds/Student Support Services Officer
SCSD SOCIAL HISTORY GUIDE(This form is used to gather information/notes to be used to create the narrative social history)
School ID# ________________________ Initial: _______ Updated: _______
Name: _____________________________________ School: __________________________
DOB: _____________________ Age: _________ M: _____ F: _____ Date of Report: _________________
Address: __________________________________________________________________________________
Source of information: Mother____ Father____ Legal Guardian____ Other__________________________
Student lives with: ________________________________ Custody: _________________________________
MOTHER:
Age:
Home Telephone:
Cell: Work:Highest Level of Education: Address:
FATHER:
Age:
Home Telephone:
Cell: Work:Highest Level of Education: Address:
LEGAL GUARDIAN:
Age:
Home Telephone:
Cell: Work:Address:
SYRACUSE CITY SCHOOL DISTRICT
Siblings
Name AgeLiving in Home
School Grade Special Ed
Language spoken by child in the home:
______________________________________________________________________________
Other language:
______________________________________________________________________________
Interpreter needed? Yes ____ No ____
What are your child’s strengths/interests?
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Child’s favorite activities/hobbies:
1. ______________________________________________________________________
______________________________________________________________________
2. ______________________________________________________________________
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3. ______________________________________________________________________
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REFERRAL INFORMATION
Please describe your concerns regarding your child’s development:
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How long has this been a concern for you?
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What helps the problem?
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What makes things worse? _____________________________________________________________________________________
What discipline techniques are effective/ineffective at home?
______________________________________________________________________________
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Does your child exhibit any behaviors that you would like to see less of and/or do you have any
concerns about social/emotional/behaviors?
______________________________________________________________________________
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SOCIAL AND BEHAVIOR CHECKLIST
BEHAVIORCOMMENTS
(yes/no, explain)BEHAVIOR
COMMENTS
(yes, no, explain)
Difficulty with speech sounds and/or using language
Are there any safety concerns? (Example: Climbing, impulse control, playing w/dangerous items)
Fidgets/Attention Span Problems
Special fears/habits/mannerisms (Example: bangs head, rocks, puts things in mouth) Please describe.
Fine motor concerns (example: hold pencil, zipper/button)
Gross motor concerns (example: safe on stairs)
How does your child play? (likes to play independently/with others) Friendships and Peer Relationships
Sleeping habits (sleeps through night? Naps?)
Gets along with siblings/cooperative.
Tantrums Why? When? How often? Can they calm themselves?
Chores child does or helps around house. Sad/Depressed often?
Is shy or timid, outgoing or reserved?
What activity holds their interest the longest? Do you have attention concerns?
Stubborn Fire setting history
Gets easily frustrated Is impulsive
Angry oftenTemper rating: even/quickMild/strong
Anxious/worried
Moody/changes mood often
History of mental health treatment(CPEP, suicidal/homicidal Ideation)
Grief/Loss (history of) General Trauma
Is there anything else that you would like us to know about your child?
______________________________________________________________________________
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Adaptive or other Behavior rating scale:
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__________________________________________________________________________________________________________________________________________________________________________
Previous evaluations? Yes ____ No ____
Where: _______________________________________________ Date: __________________
Previous/Current services:
_____________________________________________________________________________
How often does the other parent see this child? _____________________________________________________________________________
Other important people in life: _____________________________________________________________________________
Family strengths/activities: _____________________________________________________________________________
Family Stressors: _____________________________________________________________________________
Any family history of substance abuse, alcohol abuse or mental health issues?
________________________________________________________________________
______________________________________________________________________________
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BIRTH/DEVELOPMENTAL /HEALTH HISTORY
Where was the child born? ____________________________________ Birth weight: ________
Premature? Yes ____ No ____ If yes, how many weeks? __________
Cesarean section? Yes ____ No ____ If yes, why?
______________________________________________________________________________
Any complications during pregnancy, delivery or birth? Yes ____ No____ If yes, please
explain:
______________________________________________________________________________
______________________________________________________________________________
Medication during pregnancy? Yes ____ No ____ If yes, what kind?_____________________
______________________________________________________________________________
Any use of alcohol, drugs or tobacco during pregnancy? Yes ____ No____ If yes, please
specify:
______________________________________________________________________________
______________________________________________________________________________
Did your baby pass the newborn hearing screening? Yes____ No____ Ear Infections? Yes____
No____
Has your child been screened for hearing? Yes ____ No ____ If yes,
results:________________________________________________________________________
Has your child been screened for vision? Yes ____ No _____ If yes, results:
______________________________________________________________________________
Have you or any doctor expressed any growth or developmental concerns regarding your child?
Yes___ No___
If yes, have/are they being monitored for this concern?
______________________________________________________________________________
Current medical provider/medications:
______________________________________________________________________________
Other current health concerns or needs:
______________________________________________________________________________
DEVELOPMENTAL MILESTONES
BEHAVIOR AGE BEHAVIOR AGE
Rolled over Put two words together
Sat alone Dressed self
Crawled Toilet trained
Walked alone Fed self with fingers
Babbled/cooed Fed self with spoon
Spoke first word Slept through the night
Tricycle Bicycle
ACADEMIC HISTORY
Previous schools attended Start/End Date
Daycare/Other (stayed w/family member) Dates
Likes School?
_______________________________________________________________________
Attendance Patterns
_____________________________________________________________________________
Parent’s view of how child does: Reading __________ Math __________ other subjects
_____________________________________________________________________________
Parent’s concerns about learning
_____________________________________________________________________________
Others in family with academic struggles
_____________________________________________________________________________
What resources do you think will help your child?
_____________________________________________________________________________
COMMUNITY AGENCY SERVICES (Counseling, After School Program, Sports, Church, CPS, PPS)
Agency/Telephone Contact Person Services
Statement of how this information was gathered: phone interview/office interview, with
whom, records review, etc. Ex: The information included in this Social History Report was
gathered during an office visit interview with Ms. Jones. Other information was also gathered
from school records.
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Name of Social Worker:___________________________________________________________
Signature:_____________________________________________ Date:____________________
725 Harrison Street, Syracuse, NY 13210 | T (315) 435-4131 | F (315) 435-5838 | syracusecityschools.com