CCJS - Social and Developmental History Form

SOCIAL AND DEVELOPMENTAL HISTORY FORM
First*
Middle*
Last*
Gender*

MaleFemale
School Attending*
Grade*
Date of Birth*

MonthDayYear
Date
Guardians Names*
Current Address*
Home Telephone*
Work Telephone*
Cellphone*
Guardians Email
example@example.com
Family History
Legal Guardianship:*

Biological MotherBiological FatherStep-fatherStep-motherAdoptive MotherAdoptive FatherFoster FamilyGuardian (specify)
Marital Status of Parents*

MarriedDivorcedSingleMarried but living apartOther
Custodial Status

Joint CustodySole Custody (Which Parent?)
Does the child have visitation with non-custodial parent?

YesNo

Please list the names and ages of all people currently living at your child’s residence:

	Name	Relationship to Child	Age	Highest Grade Achieved
Person 1
Person 2
Person 3
Person 4
Person 5

MEDICAL HISTORY
Describe any complications medications or other concerns experienced during the pregnancy (e.g., gestational diabetes, high blood pressure, preeclampsia, toxemia, etc)
Was the child full term?*

YesNo
Cesarean Section?*

YesNo
Birth Weight*
Duration of Pregnancy*
Please describe any birth or delivery complications:*

List any serious illness, injuries, hospitalizations, surgeries, or traumatic events (e.g., diabetes, seizures, convulsions, concussions, asthma, allergies, etc.)

	Child's age at the time of event	Description of the event/illness/injury
Event 1
Event 2
Event 3
Event 4

Current Medical Diagnosis

	Current Medical Diagnosis	Medical Provider's Name	Date of Diagnosis	Prescribed Medication
Entry #1
Entry #2
Entry #3

Does the child have a family history (biological parents, siblings, grandparents, aunts, uncles, cousins) of any of the following?

Learning difficulties (reading, spelling, writing, math, organization)Speech or language difficulties (articulation, stuttering, organizing/recalling words, etc.)Emotional difficulties (depression, anxiety, mood disorder, psychosis, etc.)Cognitive difficulties (may have been called mental retardation or mental handicap)Genetic medical conditions impacting developmental, learning, and emotional healthAbuses or domestic violenceSubstance abuse (drugs or alcohol)Other
Does your child experience any of the following:
Vision Problems?*

YesNo
Glasses?*

YesNo
Contacts?*

YesNo
Date of recent vision exam*

MonthDayYear
Date
Results*
Describe any vision sensitivity*
Hearing Problems?*

YesNo
Age detected*
Tubes in Ears?*

YesNo
If yes, when was the procedure done?

MonthDayYear
Date
Hearing aids?*

YesNo
Cochlear implant?*

YesNo
Date of recent hearing exam*

MonthDayYear
Date
Results*
Describe any hearing sensitivity*
Sleep Problems?*

YesNo
Describe
Taste problems?*

YesNo
Describe
Touch problems?*

YesNo
Describe
Other
What is your child's primary language*
What other languages are spoken at home*

Did the demonstrate the following behaviors within an age-appropriate time line?

	Yes	No	Don't know/Not yet show
Rolled over - 4-6 months
Sat alone - 6-9 months
Crawled - 6-9 months
Stood alone - 12-15 months
Walked alone - 12-15 months
Babbled - 6-9 months
Spoke first word - 9-12 months
Combined words together - 18-24 months
Toilet trained during the day - 22-24 months

Please check early intervention services received when your child was a toddler:*

Speech and LanguageDevelopmental TherapyPhysical TherapyOccupational TherapyBehavioral TherapyOther
School History
Daycare/Preschool/School Attended

If your child repeated a grade, what grade was repeated? Reason for retention?

Daycare/Preschool/Schools Attended

	Name of School/Daycare/Preschool	Date of Attendance
Entry 1
Entry 2
Entry 3
Entry 4

If your child repeated a grade what grade was repeated
School
Reason for retention
Has your child received private interventions or evaluations to assist with school progress?

Educational services from private entity (e.g., private tutor, Sylvan, Learning Rx, Lindamood Bell, etc.)Therapy services from private entity (e.g., speech, occupational therapy, physical therapy, vision therapy, behavioral therapy, etc.)Private evaluations/previous school evaluations (please attach previous educational reports)
Please describe the following:
Your child's school strengths*
Your child's attitude toward school*
Your child's study habits at home*
Your child's school weaknesses*
Behavioral History
Please check behaviors deemed to be a significant concern at this time:*

Fidgets, is easily distracted,Has a hard time staying seatedShifts quickly from one activity to anotherTalks excessively, interrupts often, doesn’t listenOften loses things, very disorganizedHas difficulty waiting his/her turn or inlinePoor concentrationDifficulty initiating tasksDifficulty following instructionsDifficulty completing tasksDifficulty playing quietlyOften is loudEngages in impulsive behaviorEngages in physically dangerous activitiesImmature compared to peersDifficulty making decisionsDepressed/sad moodFeelings of worthlessness or low self-esteemSleeping too littleSleeping too muchLow energy/fatigueExcessive separation difficultiesRepeatedly has nightmare/night terrorsShy/withdrawnOverly anxious or fearfulCries easilyTemper tantrumsArgumentative with adultsArgumentative with peersRapid mood changes/mood swingsSuicidal thoughts/actsDefies adult requests and rulesBlames others for mistakesDeliberately annoys othersPhysically aggressive toward peersPhysically aggressive toward adultsAngry/resentfulEasily frustratedPoor appetiteOvereatsOften complains about bodily achesExcessive worry about eventsExcessive worry about othersOften is truant or lateExcessive need for reassuranceLiesStealsSubstance abuse - drugsSubstance abuse - alcoholStereotyped mannerismsOften swears or uses obscene languageCompulsive ritualsAtypical/unusual fascinations or thoughtsHallucinations - VisualHallucinations - AuditoryFire settingSelf-mutilation/self-injuryDestroys others’ propertyHarms animals
Does your child display any of the atypical behavioral patterns?

Preoccupation with specific topics or objectsEccentric forms of behaviorNot understanding or aware of others’ viewsAtypical facial or emotional responses to situationsDesires things to be in a specific way and routineUnusual mannerisms and ways to move bodyTrouble understanding jokes and humorDifficulty adjusting to new surroundingsDifficulty adjusting to changes in plans/routinesOther
Please indicate and specify reasons your child received the following:

CounselingDepartment of Children’s ServicesJuvenile court or probationMental health hospitalizationPsychological evaluation
Reasons for Counseling
Reasons for Juvenile court or probation
Reasons for psychological evaluation
Reasons for Department of Children's Services
Reasons for mental health hospitalization
How does your child get along with adults at home*
How does your child get along with siblings in the home*
How does your child get along with peers?*
How many friends does your child have?*
What activities does your child do with his/her friends?*
What are your child's favorite activities?*
What are your child's behavioral and social strengths?*
What are your child's behavioral and social weaknesses*
Please indicate which occurred during the past year:

Relocation to new cityNew homeLoss of family memberIllness of family memberChange in family incomeJob change/lossNew addition to the familyOther
Other information you believemay be relevant to in the evaluation of your child:
Should be Empty:

SOCIAL AND DEVELOPMENTAL HISTORY FORM

Family History

MEDICAL HISTORY

Does your child experience any of the following:

School History

Please describe the following:

Behavioral History