Iredell/Statesville School District
Social/Developmental History/Needs Assessment
To be completed at the beginning of Tier 3: Part 1
IDENTIFYING INFORMATION
Today’s date: ______School: ______Student Name: ______
Sex: ______Grade: ______Date of Birth: ______Person completing form: ______
Relationship to child: ______Home number: ______Cell: ______Work ______
FAMILY INFORMATION
Please list all people living in the household:
Name / Relationship to child / AgeWho has custody of the child? ______
Relationship to child:______Address:______
Telephone Numbers: ______
Parent’s separated/divorced Y/N______When: ______
Either parent remarried? Who? ______When: ______
Language spoken in home: ______
CHILD MEDICAL HISTORY
Please circle any medical or mental health issue/diagnosis of child below:
Allergies / Coordination Problems / High Fevers / Self HarmAnorexia / Depression / Hyperactive / Sexual Abuse
Anxiety / Diabetes / Liver problems / Skin Rashes
Asthma / Drug/Alcohol Use / Memory loss / Sleeps too much
ADD / Ear Infections / Motor tics / Sleeps too little
ADHD / Frequent headaches / Muscle weakness / Speech issues
Autism/Asperger’s / Frequent stomach aches / Over/underweight / Suicidal
Broken Bones / Growth problems / Paralysis / Thyroid problems
Bulimia / High blood pressure / Physical Abuse / Tourette’s Syndrome
Cancer / Heart problems / Seizures / Toileting issues
Concussions / Traumatic Brain Injury
Has the child ever been hospitalized? If so, when and why? ______
Current Medications? ______How long on:______
How many hours per night does your child sleep? ______Does your child sleep in their own bed?______
Name, Address, & number of Medical Doctor: ______Date of last appt.______
Name,Address, & number of Mental Health Therapist/Psychiatrist: ______Date of last appt. ______
CHILD DEVELOPMENTAL HISTORY
Did the mother have any complications or health issues during pregnancy? If so, explain. ______
______
Did the mother use alcohol or drugs during pregnancy? ______
Was the baby full – term or premature? How many weeks early? ______
Did the baby have any problems after birth? ______
At what age did the child reach the following developmental milestones?______
______Crawl ______Walk ______Spoke 1st words ______Spoke in complete sentences ______Sat alone ______Toilet trained
CHILD SOCIAL/BEHAVIORAL SKILLS
Does the child get along with other children? Y/N______Who are your child’s close friends? ______
Are you comfortable with your child’s choice of friends? ______If not, explain: ______
Does the child participate in any group activities such as scouts, sports team, and clubs? List: ______
What does your child do for fun? ______
What do you see as your child’s strengths? What are they good at? ______
______
What does your child do when angry? ______Pout _____Cry _____ Stomp _____Slam doors _____Curse _____Hit self _____Hit others _____Hit walls _____Destroy things _____Threaten to harm self _____Threaten to harm others _____Mumble _____Say they hate you
Does the child display any aggression towards parents, pets or siblings?Explain:______
Please circle any behavioral issues your child has ever displayed:
StealsLiesHarms othersHarms selfCries easilySeems anxious
Has mood swings Avoids schoolRuns awayFearfulDepressed
Fire setting Plays sick to avoidCursesParanoidBullies others
Anger outbursts Sexual behavior Animal crueltyDrug/alcohol use
Doesn’t sleep Won’t try new things Imaginary friendsSees things that aren’t there
Doesn’t like to be alone Doesn’t follow rules Doesn’t pay attention Difficulty concentrating
Doesn’t make eye contact Dislikes loud noisesAvoids physical touchAnnoyed by clothing tags
Hears things that aren’t there
What are your primary concerns for your child at home? ______
______
What adult does your child have a positive relationship with? ______
______
CHILD EDUCATIONAL HISTORY
Are you happy with your child’s academic performance at school? ______
What are your primary concerns for your child at school? ______
______
Has the child repeated a grade? ______Has the child ever received speech, academic, or behavioral services while in school? ______
Has your child ever been recommended for testing at school?______When?______
How many hours per night does your child spend completing homework ______Will they start it without a prompt from you? ______Do you have to help them complete it? ______
Parents/guardians last school year completed? Mother______Father______
Parents/guardians employment: Mother______Father ______
Does your child have chores at home? ______List them below. Do they have to be prompted? ______Do they complete them?______
Does your child use a chore chart or family schedule at home? ______
Family communication style:
_____Each person talks over the other ____one person controls the conversation _____each person is heard and feels respected _____ we don’t talk ______what my spouse says goes _____ my spouse talks so much I tune them out _____Mother screams _____Father screams _____my child doesn’t listen to me _____ we don’t say speak kindly to each other _____ I try to say something nice to my child every day _____ my spouse and I argue a lot ____ my spouse and I argue in front of the kids
Family discipline style: Circle all that apply
“Child is in control in my house””I try to set limits but my spouse let’s the kids do whatever they want” “I don’t get any support from my spouse” “I am always the bad guy” “my child knows that they are to be seen and not heard” “my parent’s were strict and I turned out ok” “spanking is fine” “I never spank my child” “my child is my best friend” ”my child breaks off their own switch from the tree” ”I follow thru on my threats” “I am a pushover” Other ______
Does your child know what consequence they will receive at home for breaking rules, being disrespectful, etc.? ______
Family time is spent:
**Help parent/guardian understand that we would like to collect data on helpfulness of MTSS Tiered Interventions by assessing pre and post intervention effectiveness**
**Ask parent/guardian to record the NUMBER OF TIMES PER MONTH they do the following activities**
**4 MTSS Grant schools will ask the same questions again upon student moving back down to a lower tier **
# of times per month Family time is spent on the following activities:
eating dinner together ______playing games together ______watching TV together ______playing video games together ______going to my child’s sporting events ______home chores ______going to church ______volunteering ______reading ______exercising ______taking care of pets ______visiting with friends/neighbors ______visiting family members ______resting ______participating in a hobby ______playing a sport ______having a family meeting ______Other ______
FAMILY STRESSORS
Has either parent experienced….
____Recent loss of job____Unplanned pregnancy____Deployment____Divorce____Financial
____Long term unemployment ____Job change____Recent move____Jail ____Loss of license ____Recent health diagnosis ____Student moved to new school
____Death of family member Who & Date ______Remarriage – Who & Date______Other ______
FAMILY MEDICAL HISTORY
Please list the child’s relationship to family member who has a history of the following:
Alcohol/drug abuse / Huntington’s ChoreaAnxiety / Learning problems
Autism / Mental Retardation
Cancer / PTSD
Depression / Seizure Disorder
Diabetes / Sickle Cell Anemia
Heart Disease / Suicide
High Blood Pressure
FAMILY NEEDS
_____Access to health care_____Paying Electric/Power Bills_____Dental care
_____Access to transportation_____Job_____Alcohol/drug treatment _____Food _____Academic tutoring _____Community church
_____Clothing_____Insurance_____Translation services
_____Childcare_____Car_____Friends
_____Medication Management_____Family/Individual/Marriage Counseling_____Other______
CHILD INTERVIEW: Part 2
The following set of questions are for students grades K – 4.
What are 3 things you think you are good at or that you like about yourself?
______
______
What do you like to do for fun after school? ______
What is your bedtime ? ______Do you fall right to sleep?______Do you wake up in the night? ______If so, can you fall right back to sleep? _____ What wakes you up? ______
Do you have a computer, video game console, or TV in your bedroom? ______Do you take medication for sleep? ______
What scares/worries you the most?______
How do you feel about riding the bus? ______
What do you like about school? ______
What’s your favorite subject / class? ______Why? ______
What is your least favorite subject / class? ______Why?______
What do you do after school? ______
______
Do you usually have homework? ______Does it take a long time to finish? ______
Do you ever forget to do it? ______Do you do it and forget to turn it in?______
What do you usually get in trouble for at school? ______
______
How do you feel when you get in trouble? ______
What do your classmate’s say when you get in trouble? ______
What do your teacher’s say when you get in trouble? ______
What do you do when angry? ______Pout _____Cry _____ Stomp _____Slam doors _____Curse _____Hit self _____Hit others _____Hit walls _____Destroy things _____Threaten to harm self _____Threaten to harm others _____Mumble _____Say I hate you ______Listen to music ______Read _____ Write
_____Talk on phone ______Get on the computer _____ Play a video game _____ Exercise _____ Play a sport _____ Go to sleep ______Cry
Do you one really good friend or lots of good friends? ______Who is your best friend? ______
How would you describe yourself? ______Happy _____Sad _____Annoying _____Funny _____ Shy _____ Nice _____ Angry ______Cool _____ Dumb_____ Cute ____ Pretty _____ Ugly _____Smart ____Popular _____Good dresser _____Poor _____Lucky _____Teachers pet _____Athletic _____Silly _____Bully ____Mean _____Troublemaker ____I don’t have friends _____Rich _____Friendly _____Helper _____ Talkative
Who are you closest to in your family? ______
Who gives consequences at home? ______What is it? ______
Do you get along with your siblings? ______
If you could change one thing at home, what would it be? ______
______
Ask students how many TIMES PER MONTH they do the following activities**
4 MTSS Grant schools will ask the same questions again upon student moving back down to a lower tier **
How many times per month is Family time spent participating in the following activities?:
eating meals together ____playing games together ____watching TV together ____ playing video games together _____ going to my child’s sporting events _____ home chores _____ going to church _____ volunteering _____ reading _____ exercising _____ taking care of the pets _____ resting _____ playing a sport _____ visiting with friends/neighbors _____ participating in a hobby ______having a family meeting _____ Other ______
Have you thought about what kind of job you would like to have when you graduate high school? ______
______
What kind of help do you think you might need to be successful in school? ______
CHILD INTERVIEW: Part 2
The following set of questions are for students grades 5 – 12.
What are 3 things you think you are good at or that you like about yourself?
______
______
What do you like to do for fun after school? ______
Is there something you want to do that you aren’t doing? ______
Tell me about your sleeping habits. What time do you go to bed? ______
Do you fall right to sleep?______Do you toss and turn? ______Do you lay in the bed for a while & think about your day? ______Do you wake in the night? ______If so, can you fall right back to sleep? _____ Do you have electronics in your bedroom? ______Do your parents know? _____ How long do use your electronics before going to sleep? ______Do you take medication for sleep? ______
What scares/worries you the most?______
How do you feel about riding the bus? ______
What do you like about school? ______
What’s your favorite subject / class? ______Why? ______
What is your least favorite subject / class______Why?______
What would you change about school if you could? ______
______
Tell me about your routine after school? ______
______
How long do you spend on homework a night? ______Do you ever forget to do it or blow it off? Why______
______
What do you usually get in trouble for at school? ______
______
How do you feel when you get in trouble? ______
Have you tried to stop getting into trouble? ______What did you do? ______Did it work? ______
What do your classmate’s say when you get in trouble? ______
What do your teacher’s say when you get in trouble? ______
What do you do when angry? Pout _____Cry _____ Stomp _____Slam doors _____Curse _____ Hit self _____ Hit others _____ Hit walls _____ Mumble _____ Read _____ Destroy things _____ Write______Threaten to harm self _____ Exercise _____ Play a sport _____ Cry_____ Threaten to harm others _____ Say I hate you ______Listen to music ______Talk on phone ______Get on the computer _____ Play a video game _____ Go to sleep ______Other ______
Are you the kind of kid who has one really good friend or lots of good friends? ______Who is your best friend? ______
How do you think your friend’s would describe you? Happy _____Sad _____Annoying _____Funny _____ Shy _____ Nice _____ Angry ______Chill _____ Cool _____ Dumb_____ Cute Alright _____Poor _____Lucky _____Teachers pet _____Athletic ____ Pretty _____ Ugly _____Smart ____Popular _____ Flirt_____Good dresser _____Silly _____Hot _____Bully ____Mean _____Troublemaker ____I have no friends _____Wealthy _____Friendly _____Partier _____Moody _____
Would you agree with them? ______Why? ______
______
**Please state to the adolescent you are asking these questions to help you, help them. The following substance use questions will not be shared with school personnel or the parent unless their substance use behavior makes them a danger to self or others or it their substance use ever becomes a school policy violation**
Have you been approached by peers to use drugs or alcohol? ______Did you? If not, do you have a plan for when that happens? ______What? ______
If you have or currently using drugs/alcohol, what and how often? ______
______
When did you first start ______
Do your parents know? ______If yes, how did they find out? ______
______
Have you been in trouble with the law? ______
Who are you closest to in your family? ______
Who gives consequences at home? ______What? ______
How do you feel about your siblings? ______
If you could change one thing at home, what would it be? ______
______
**Ask students how many TIMES PER MONTH they do the following activities**
**4 MTSS Grant schools will ask the same questions again upon student moving back down to a lower tier **
Number of times per month Family time is spent participating in the following activities:
_____ eating meals together ____playing games together ____watching TV together ____ playing video games together _____ going to my child’s sporting events _____ home chores _____ going to church _____volunteering _____ reading _____ exercising _____ taking care of the pets _____ visiting with friends/neighbors _____ visiting with family_____ resting _____ participating in a hobby _____ playing a sport _____ having a family meeting _____Other ______
What would you like to do when you graduate high school? ______
______
What’s your plan to make that happen? ______
______
What kind of help do you think you might need to be successful in school? ______
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