Parental Report of Social and Developmental History

Richmond Community Schools

Parental Report of Social and Developmental History

(to be completed in interview with parent)

Student Birth Date

School Grade Teacher

Student Address:

Name of parent/guardian providing information:

Name of person interviewing parent:

BACKGROUND INFORMATION

Family Information

Mother’s name:Phone: Work #:

Email Place of employment/occupation:

Father’s name: Phone: Work #:

Email Place of employment/occupation:

Stepparent’s name:Phone: Work #:

Place of employment/occupation:

Guardian: Phone: Work#:

Email Place of employment/occupation:

Parents are:married _____ separated _____ divorced _____ single _____

Who has legal custody of the child?

If parents are separated/divorced, how old was student when separation/divorce occurred?

If parents are separated/divorced, how often does the student see non-custodial parent?

List all people living in household:List any siblings living elsewhere:

Name/AgeRelationship to StudentName/Age

Pregnancy and Birth

General health of mother during the pregnancy:Age of mother at pregnancy:

During pregnancy, did mother:

• Take medication?YesNoIf yes, what & why?
• Smoke?YesNoIf yes, how much?
• Drink alcohol?YesNoIf yes, how much?
• Use drugs?YesNoDescribe:

Was birth a Cesarean section?YesNoIf yes, why?

Was pregnancy full-term?YesNoIf premature, by how many weeks?

Child’s birth weight: Number of days child hospitalized after birth:

Were there any other pregnancy or birth complications (please explain):

Development:

Please indicate the age at which your child first demonstrated each of the following behaviors. If you are not certain of exact age, provide an estimate.

Age child crawled

Age child walked alone

Age child spoke first word

Age child put several words together

Age child became toilet trained

Additional Comments: ______

______

MEDICAL HISTORY

Complete any of the following that apply to your child:

Age Problem

Problem Description of Problem Observed

Growth problems

Serious illness

Injuries

Surgeries

Hospitalizations

Complications from fever

Seizures

Vision problems

Hearing problems

Speech problems

Other

Other

Present Health

Family Doctor/Pediatrician: Phone #:

Specialist NameSpecialty AreaPhone #

______

______

______

Does your child wear glasses?YesNo

Has your child ever had ear tubes?YesNo

Has your child ever been diagnosed with ADHD?YesNo

Has your child ever been diagnosed with any medical problems?YesNo

If yes, describe:

Your child’s current medicationDosageAge begunReason for medication

SCHOOL HISTORY

Attendance History

Please list in order the previous schools/preschools your child has attended:

School Location Grades Dates

Interventions:

Has your child:

• Been retained in a grade? Yes No

If yes, Grade: ______School:______

• Received tutoring outside of school? Yes No

Where: ______Dates: ______

• Been formally evaluated other than by Richmond Community Schools? Ye No

By whom?: ______Dates: ______

(Attach previous evaluation if available)

• Participated in occupational, physical, or speech therapy outside the

school system? Yes No

Dates: ______Describe: ______

• Participated in an early development program such as Birth to Five, First Steps, etc.? Yes No

Dates: ______Describe: ______

Current Concerns

Describe the concerns which you have about your child and his or her school performance:

Have you found anything at home that helps the problem?

What makes it worse?

SOCIAL-EMOTIONAL FUNCTIONING

Behavior at Home

Please Describe:

How your child typically spends his/her free time:

Responsibilities your child has at home:

Activities, clubs, or groups in which your child participates:

Any factors at home which may be negatively affecting your child (i.e., marital problems/divorce, illness, death, financial problems, changes in family makeup, etc.)?

Interventions:

Please describe:

Types of discipline used at home:

Child’s typical reaction to discipline:

Has your child ever received professional counseling?YesNo

If yes, date of initiation until

Name of agency

Therapist

Was the counseling helpful?YesNo

Explain

Does RCS have a signed release permitting contact with the therapist?YesNo

Please check the positive characteristics that apply to your child:

______Puts forth good effort______Wishes to please

______Attentive______Listens appropriately

______Persistent in efforts______Follows household rules

______Completes homework______Seeks help when necessary

______Cooperative______Gets along well with siblings

______Makes friends easily______Gets along well with parents

______Good sense of humor______Gets along well with other adults

______Fun-loving______Gets along well with other children

______Curious/inquisitive______Affectionate

______Compassionate______Kind to others

______Helpful______Other______

______Other______Other______

Please check any of the following characteristics that apply to your child:

______Inattentive______Distractible

______Excessively active______Restless when sleeping

______Acts before thinking______Frequently “in trouble”

______Clumsy______Does not do what he/she is told

______Moody______Quick to anger/temper tantrums

______Seems unhappy______Cries easily

______Withdrawn______Lacks energy

______Shy______Lacks motivation

______Tires easily______Difficulty following directions

______Disorganized______Low self-esteem

______Dislikes school______Easily frustrated

______Gives up easily______Difficulty getting along with other

______Other______children

What are some of your favorite things about your child?

What family and community resources are available as supports for you and your family?

Is there anything else you would like us to know about your child?

Parent Report Page 1 of 5

Revised 8/11/09