Parent Interview for Social Developmental Study

Student Name: ______

Parent(s)/Guardian(s): ______

Date of Interview: ______

FAMILY STATISTICS

Child Resides with: ______Relationship to child: ______

Language Spoken at home: ______

Biological Father Information:Biological Mother Information:

Name: ______Name: ______

Current Address: ______Current Address: ______

Telephone Number: ______Telephone Number: ______

Racial Background: ______Racial Background: ______

FAMILY MEMBERS/SIGNIFICANT OTHERS IN THE HOME:

Name / Age / Highest School/Grade / Occupation/Hours / Relationship to Child

Significant family members not in the home:

FAMILY MEMBERS/SIGNIFICANT OTHERS IN THE HOME:

Name / Age / Highest School/Grade / Occupation/Hours / Relationship to Child

Significant family members not in the home:

Health History

Allergies: Yes _____ No _____ Describe: ______

______

Serious Accidents: Yes _____ No _____ Describe: ______

______

Head Injury with Loss of Consciousness: Yes _____ No _____ Describe: ______

______

Serious Illness: Yes _____ No _____ Describe: ______

______

Chronic Illness: Yes _____ No _____ Describe: ______

______

Hospitalizations: Yes _____ No _____

If yes: Length of hospitalization: ______

Condition for which hospitalized: ______

Child’s Age:______

Other Medical Problems: ______

Present Medications: ______
Type:______Type: ______

Dose:______Dose:______

Frequency:______Frequency: ______

Family Functioning

  1. How would you describe the student’s relationship with his/her Primary Female Caregiver (mother/stepmother/grandmother/legal guardian)?
  1. How would you describe the student’s relationship with his/her Primary Male Caregiver (father/stepfather/grandfather/legal guardian)?
  1. How is the student’s relationship with his/her Biological Parent who is not the Primary Caregiver or does not live in the home?
  1. How would you describe the student’s relationship with his/her siblings?
  1. How would you describe the student’s relationship with extended family?
  1. Does the family spend time together? How often? What does the family do together?
  1. Were there any complications with the student’s birth or when pregnant with student?
  1. Have there been any significant losses/deaths/moves/divorces/re-marriages that have had an impact on the student?
  1. Does the student have chores that he/she needs to complete daily/weekly? Does he/she need to be reminded to complete chores? How well does the student complete the chores?
  1. How is the student disciplined at home (are things taken away, etc.)? (forms of punishment used)
  1. How does he/she react to being disciplined/punished?
  1. How would you describe the student (kind, funny, happy, helpful, caring, loving, etc.)?
  1. Do you have any concerns with the student’s behavior at Home? If so, what?

Community and Cultural Factors

  1. How long have you lived in the house you are currently living in?
  1. Own home or rent:
  1. Do the parents visit relatives/friends:
  1. Cultural traditions practiced (holidays, special events):
  1. Family religion/church involvement:
  1. Are there any specific needs school could potentially/possible be of assistance:
  1. AGENCY INVOLVEMENT (Public Aid, DCFS, SSI): (not in report)
  1. Are there any tensions in the home (financial, marital, medical problems)? (not in report)
  1. Are there any drug or alcohol problems in the family that may affect the student (or affected the student in the past)? (not in report)
  1. Has the student been involved with the court or has had any police contact?
  1. Do you have any concerns about his/her behavior needing more serious interventions (with law enforcement or court)?

Extra-Curricular Activities

  1. Is student currently involved or has been involved in the past in any clubs/sports at school? If yes, which ones and for how long.
  1. Is student currently involved or has been involved in the past in any clubs/sports within the community or at church? If yes, which ones and for how long.
  1. Does the student want to be involved in any sports/clubs but chooses to not get involved? If so, why is the student not involved?
  1. What are the student’s other interests and activities? What are the activities he/she likes the least?

Social and Behavior Checklist

_____Has difficulty with speech_____Has frequent tantrums

_____Has difficulty with hearing_____Has frequent nightmares

_____Has difficulty with language_____Has trouble sleeping (describe): ____

_____Has difficulty with vision______

_____Has difficulty with coordination_____Rocks back and forth

_____Prefers to be alone_____Bangs head

_____Does not get along well with siblings_____Holds breath

_____Is aggressive_____Eats poorly

_____Is shy or timid_____Is stubborn

_____Is more interested in things than_____Has poor bowel control (soils self)

in other people_____Is much too active

_____Engages in behavior that could be _____Is clumsy

dangerous to self or others (describe)_____Has blank spells

______Is impulsive

______Shows daredevil behavior

_____ Has special fears, habits, etc?_____ Is slow to learn

______Gives up easily

______Wets bed

_____ Bites nails_____ Sucks thumb

Other: ______

Adaptive Behaviors

  1. Adaptive behaviors include real life skills such as being safe, handling food safely, follow rules, and ability to work, cleaning, making friends, social skills, and taking personal responsibility.
  1. Is the student capable of performing tasks of daily living (grooming, dressing self, make and eat on own, clean and bath self, daily hygiene, and brushing teeth)?
  1. How many hours of sleep does the student get a night? Does he/she sleep through the night?
  1. How many times a day does the student eat? Do you worry that he/she is not eating enough or eating too much? How is his/her diet?
  1. Does the student have friends (in/out of school)?
  1. Does the student have difficulty making and/or keeping friends?
  1. How is the student’s socialization (making friends in school and community, problem solving abilities, general self-esteem, and ability to be honest, cooperative, trustworthy, empathetic, and fair)?
  1. How is the student’s communication skills (ability to comprehend information received, express self, and disclose thoughts/feeling)?
  1. How is the student’s homework skills (organization, ability to work independently or prefers a group, following of directions)?
  1. How is the student’s self-direction (ability to learn and follow a schedule, resolve problems, complete required tasks, ability to be assertive, make good choices)?
  1. How is the student’s decision making (ability to choose right from wrong)?
  1. Are there any concerns with his/her safety (either physical or mental health)?

School

Year / Grade / Location / Program
Reg/SPED / Absences
Pre-K
K
1st
2nd
3rd
3rd
4th
5th
6th
7th
8th

***Repeated any grades?

  1. What are the student’s academic strengths?
  1. What are your concerns academically with the student?
  1. Do you have any concerns with the student’s behavior at School? If so what?
  1. Do you have any concerns with the student’s relationship with teachers/staff? How does he/she get along with his/her teachers/staff?
  1. How does the student get along with his/her teachers?
  1. How does the student get along with his/her peers?
  1. Does the student have friends in school or community?
  1. Do you think the students friends are a positive or negative influence on the student?
  1. Do you know what grades the student is currently getting or has been getting?
  1. What is the student’s favorite subject? Why?
  1. What is the student’s least favorite subject? Why?
  1. What do you believe the student needs to work on? What needs to improve?

1