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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
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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?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Child’s favorite activities/hobbies:
1. ______________________________________________________________________
______________________________________________________________________
2. ______________________________________________________________________
______________________________________________________________________
3. ______________________________________________________________________
______________________________________________________________________
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REFERRAL INFORMATION
Please describe your concerns regarding your child’s development:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How long has this been a concern for you?
______________________________________________________________________________
What helps the problem?
______________________________________________________________________________
What makes things worse? _____________________________________________________________________________________
What discipline techniques are effective/ineffective at home?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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?
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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
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Is there anything else that you would like us to know about your child?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Adaptive or other Behavior rating scale:
______________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
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:
______________________________________________________________________________
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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
_____________________________________________________________________________
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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.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Name of Social Worker:___________________________________________________________
Signature:_____________________________________________ Date:____________________
725 Harrison Street, Syracuse, NY 13210 | T (315) 435-4131 | F (315) 435-5838 | syracusecityschools.com