Social-Developmental History Questionnaire
Carolina Total Child
Today's Date
*
/
Month
/
Day
Year
General Information
Childs Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Age
*
Grade
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person Providing Information?
*
First Name
Last Name
Relationship to Child?
*
Who Does the Child Live With?
*
Both Parents
Mother
Father
Other
Father's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Mother's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Guardian's Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please List All People in Child's Immediate Family
Family Member's Name
Relationship
to Child
Age/Grade
Living in
Household?
1
2
3
4
5
6
List All Non-Family Members Living in Household
Non-Family Member's Name
Relationship
to Child
Age/Grade
1
2
3
4
Are biological parents of child currently?
*
Married
Separated
Divorced
Never Married
Other
If separated or divorced, who is the primary custodial parent?
Mother
Father
Other
If separated or divorced, how do you feel your child has adjusted?
Are you currently in any form of legal litigation regarding the child/children?
Custody, child support, guardian ad litem, etc.
Have there be any significant changes in the home over the last few years?
*
What do you feel are your child's strengths?
*
What do you feel are your child's weaknesses?
*
Briefly describe your concerns for your child:
*
Is there a family history of any of the following?
Yes
Please describe and give details
Learning Difficulties/Disability
Speech or Language Problem
Developmental Disorder
Emotional Problems
Academic Issues
Drug or Alcohol Addiction
Health Information
Describe the state of your child's current health?
*
Excellent
Good
Fair
Poor
Is your child taking any medication?
*
Yes
No
If Yes, (Please Specify)
Has your child been identified as having a disability?
*
Yes
No
If Yes, (Please Specify)
Has your child ever received psychological counseling?
*
Yes
No
If Yes, (Please Specify)
Has you child had any of the following?
Yes
Please describe and give details
Head Injury
Seizures
Surgery/Hospitalization
History of Ear Infections
Allergies and/or Asthma
Vision Problems
Hearing Problems
Frequent Nightmares
and/or Bedwetting
Other Health Problems
Behavioral Information
During childhood, were any of the following present to a significant degree?
Did not enjoy cuddling
Difficult to comfort
Colicky
Excessive irritability
Diminished sleep
Poor eye contact
Fascination with certain objects
Other
How active has your child been from an early age?
How well has your child been able to maintain focus or concentration, or pay attention to tasks in school and/or home?
Especially tasks they find challenging, a chore or boring
How well has your child been able to cope with transition, change or denied his/her own way?
How well has your child been able respond to new things?
People, places, things, etc.
How well do you feel your child articulates their emotions?
Anger, happiness, disappointment, fear, failure, loneliness, etc.
Describe your child's basic temperament?
Rapid mood swings or even tempered, etc.
How predictable are your child's patterns?
Activity, sleeping, eating, academics, etc.
Please check all behaviors or characteristics your child has exhibited over the past year
Destructive behavior
Is affectionate with family and friends
Responds well to authority
Boundless energy
Poor judgment
Withdrawn and/or sullen
Cruelty to animals
Disorganized, looses things often
Sudden outbursts
Physical aggression
Frustrated easily
Shifts from one activity to another
Has difficulty paying attention
Fidgets or squirms in seat
Appears to daydream or "zone out" often
Appears depressed and unhappy much of the time
Explosive temperament
Frequently complains about aches and pains
Appears to have low self-esteem
Prefers to be alone ("a loner")
Starts fires
Lacks motivation
Steals or lies
Becomes upset with change
Fearfulness
Frequent peer and/or family conflicts
Does not appear to listen to what is being said
Always worrying about something
Nervous habits (nail biting, hair twirling, etc.)
Issues with sexuality
Issues with technology (phone, computer, social media, etc.)
Other
How often is each of the following settings a problem for your child?
Rarely
Sometimes
Frequently
Never
While getting ready for school?
When eating at the dinner table?
When playing by him/herself?
When playing with a sibling or child in neighborhood?
When with a babysitter or daycare?
When in public places?
When in the car?
When told to do something he/she doesn't want to do?
During sit-down or homework time?
When watching TV or playing video games?
When it is time for bed?
How would you describe your child's personality at home?
How does your child get along with siblings, if any?
Which adult would your child prefer to talk about their feelings/problems?
Who is the family member your child feels closest?
Who is the person primarily responsible for discipline in the home?
What is the most effective way to deal with your child's behavior problems in the home?
Talking, positive reinforcement, time-out, grounding, loss of privileges, spanking, etc.
How does your child respond to discipline?
List any "responsibilities" your child has at home?
Taking out trash, vacuum, washing the dog, mowing the lawn, etc.
Does your child do these regularly?
Yes
No
Does your child need frequent reminders?
Yes
No
What time does your child go to bed?
Hour Minutes
AM
PM
AM/PM Option
What time does your child wake up?
Hour Minutes
AM
PM
AM/PM Option
Does your child sleep well?
Yes
No
How much time does your child spend watching TV?
How much time does your child spend playing computer/video games?
How much time does your child spend on their phone?
Texting, social media, youtube, etc.
Have any other members of the family expressed concern about your child's behavior?
Yes
No
If Yes, please explain
Social Behavior
How would you describe your child's peer relationships and choice of friends?
How many close friends, age and gender, shy, outgoing, leader, follower, associate with scholars, associate with troublemakers, etc.
How does your child interact with other children in the neighborhood?
Educational History
How does your child feel about school?
How motivated do you feel your child is to learn?
About how much time does your child spend doing homework each night?
How much of a struggle is it for your child to do homework?
Never
Sometimes
Often
Does your child receive any special services?
IEP, 504 plan, Gifted/Talented and Honors/AP etc.
Submit
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