CHILD LIFE HISTORY NARRATIVE
Child's Name:
DOB:
Sex: / Race: Ethnicity:Social Security Number: / Place of Birth:
Citizenship Status: / Religion:
Eye Color: / Height:
Hair Color: / Weight:
I. Child's Description, Personality and Current Functioning: Include child’s physical appearance, origin of child's name and the name the child is currently known by, child’s personality using behavioral descriptors (interaction with peers and adults, what child does best, what is special about child, what does the child perceive as his/her best qualities, activities in which the child participates), and current functioning of the child (child's current physical, emotional, cognitive and social level using specific behavior descriptors to show age appropriate or developmental lags, level at which child is functioning in terms of self care, communication, and visual and motor skills and how these abilities affect his/her daily living, specific special needs of child,services given to overcome developmental delays and progress, and child's behavior that are most rewarding and most annoying to the foster parent).
II. Medical History: Includechild's delivery, PKU,VDRL, HIVresults, prenatal care, drug or alcohol use during pregnancy, specialists care, hospitalizations, medication history, significant doctor's visits, dental history, and immunization records. Include medical history before child came in care. (attach records)
II. Developmental History:Include history of major developmental milestones (i.e. age first sat alone, crawled, pulled up, walked, first word, first sentence, first tooth, toilet trained, weaned) in the child's life and the ages at which they occurred, testing and assessments, delays, andfunctioning. (attach reports)
IV. Psychological/Psychiatric History: Include the results of previous psychiatric and/orpsychological evaluations, reasons progress and prognosis ofpsychiatric hospitalizations,medications, placement implications and child's ability to be self-sufficient, and self supporting as an adult. (attach reports)
V. School Experiences/Day Care: Includechild’s grade and academic functioning, favorite and least favorite subjects, the results of educational and standardized testing, number of schools attended, adjustment to new schools, problems and methods of handling, ever been retained andwhat grade, relationship with peers and staff,and all special educational needs and services/adjustment. (attach records)
VI. Placement History: Include age at initial placement and child's understanding, age at subsequent placement(s) or moves, reason(s) for any change(s) in placement, reaction of child to changes in placement, ability of child to adjust and attach to new nurturing figures, and attachment to current foster family.
VII. Birth Family History: presenting problems at initial contact, summary of activities, services given and actions taken throughout birth family contact with agency (efforts of reunification including strengths and weaknesses of family that affected family unity, general living conditions, management of home and adequacy of the physical facility, adequacy of care and training of child), degree of family's involvement in school, church and neighborhood activities, economic and social status of family, their feelings regarding their status, attitudes of family toward placement and the possible effects on each member of the family, quality of nurturing; trust and attachment level of family members, attachment of the child to each immediate family member, relatives outside immediate family and their significance to child, relationships of each parent to the child and the interactions between them, relationships of siblings and the interaction between siblings, explanation about siblings placed separately, family's willingness and ability to assist child in separation from them, and family's desire regarding contact when child reaches twenty-one. (attach Form 553 or 561)
VIII. Child's Readiness for Adoption: IncludeifLife Book has been completed, explanation whyLife Book has not been completed,child's understanding and feelings around being placed for adoption, how much and what type preparation this child needs to be ready to move into an adoptive home, contact with foster family need to be maintained, will foster family be able to assist child in moving into adoptive home, description of family needed by this child, special qualities, skills and resources a family must possess to parent this child, behaviors that family needs to be prepared to deal with when child placed, if there is no adoptiveresourcesidentified described child's specific recruitment plan, and resources needed and length of time estimated for child to be emotionally ready to move into adoptive placement.
Note: Following forms should be attached with this narrative: Form 400, Form 432, Form 419, Siblings Waiver (if applicable), Birth Certificate (long form), TPR Court Orders/Voluntary Surrender on each parent, Death Certificate of Parents (if applicable), Divorce Verification (if applicable), Putative Father Registry Form, Form 149, Form 150, Form 151 and Indian Child Welfare Documentation (if applicable).
Case Manager: / Date:
County DFCS
Telephone: