Completed prior to SAT meeting
Student Case History
Student’s Full Name:
Student Common Name: Birthdate:
Person Providing Information: Relationship:
Date of intake: //
Interviewer:Position
Information obtained through:
Phone Interview Records Review Completed Form
Personal Meeting Health History Unreturned
A.FAMILY INFORMATION
Child resides with: (Check box that applies)
Both Parents Mother/ Step Father Foster Parent
Mother Father/ Step Mother Other
FatherGuardian
List all brothers and sisters and ages:
Child / Age / Child / AgeAre there other persons living in the home? Yes No If Yes, please explain ______
Family/ Guardian Information
Parent/ Guardian Name(s):
Father: ______
Mother: ______
Mailing Address: ______
Physical Address: ______
Home Phone: ______Cell Phone______
Father’s Employment: ______Father’s Work Phone______
Mother’s Employment: ______Mother’s Work Phone______
Have there been any recent changes in family life? (Birth, divorce, move to new home?)
yes no If yes, please explain: ______
______
B. LANGUAGE HISTORY
Child’s first language spoken: ______
Family’s primary language spoken in home: ______
Are there any other language(s) spoken in the home?Yes No
If yes, list other language(s) spoken: ______
Student’s Ethnicity: ______
C. DEVELOPMENTAL HISTORY
Development Milestone Attainment / Early / Typical / Late / n/aSitting
Crawling
Standing
Walking
First Words
First Sentences
Comments
Prenatal History
Check all boxes that apply:
Full term pregnancy Normal delivery Smoking
Alcohol consumption during pregnancy use of illegal substances during pregnancy
Mother received prenatal care by a physician
Comments
Birth History
Check all boxes that apply:
NormalPrematureLow birth weight If yes, note weight______
JaundiceVaginal DeliveryC-Section Delivery
Comments
Did the child go home with mother from the hospital Yes No
If no, please explain
D. GENERAL HEALTH HISTORY
Student’s present health can best be described as: (Check box that applies)
Excellent Good Normal Fair Poor
Is the student currently Medicaid eligible: Yes No If Yes, Medicaid #: ______
Previous Medications taken:___N/A
Current medications taken:___N/A
Describe current medical regimen and possible side effects.
Has student had any: (Check all that apply)
Serious Accidents or Injuries YesNo If yes , please explain
Operations YesNoIf yes , please explain
Illnesses YesNoIf yes , please explain
Prolonged Fevers YesNoIf yes , please explain
Convulsions YesNoIf yes , please explain
Do you have any current medical concerns regarding your child: ___ Yes ___ No
______
______
______
______
E. BEHAVIOR AT HOME AND SOCIAL HISTORY
How does your child get along with adults? ______
How does your child get along with peers? ______
Do you have any behavior concerns? ______
Has your child had any sudden changes of behavior? ______
Is your child’s activity level: normal overactive under active
Age of your child’s friends: same olderyounger
General ability to get along with others? good fair poor
What activities does your child enjoy?
______
______
What motivates your child? ______
______
F. COURT LEGAL HISTORY OF STUDENT
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n/a
Educational Surrogate
Probation Officer
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Court Appointed Special Advocate (Name): ______
Guardian Ad Litem Surrogate (Name): ______
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Court History:
n/a
no court history
pending court date
prior court history
custody of the court
delinquent
dependent
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Probation History
n/a
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regular probation
intensive probation
diversion program
alternative treatment unit
home arrest
day program
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Parental Rights:
has rights and participateshas rights and does not participate
rights have been served (attach legal documentation)
G. SCHOOL HISTORY
Preschool experience: Yes No Age entered Kindergarten: ______
Grade(s) retrained:
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K 1st2nd 3rd 4th5th 6th
Middle School High School
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School Assignment:
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The local school since enrolling.
Relatively stable educational career.
Numerous schools since enrolling in school.
More than one school during the current school year.
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Completed prior to SAT meeting
List other schools attended and grades attended: ______
Attendance:
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History of excellent attendance
History of multiple unexcused absences
Unremarkable attendance history
History of multiple excused absences
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Attendance History Comments: ___ n/a
School Behaviors:
What does your child like about school? ______
______
What does your child not like about school? ______
______
What are your child’s personal strengths? (for example: sense of humor, kindness)
______
______
What are your child’s strengths in school? (for example: math, social studies, reading) ______
______
In what areas has your child improved the most at school? ______
______
What are your areas of concern regarding your child at school?
______
______
What suggestions do you have for your child’s teacher(s)?
______
______
Other information you would like to share with the educational staff? ______
______
______
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