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SOCIAL AND DEVELOPMENTAL HISTORY

SOCIAL AND DEVELOPMENTAL HISTORY Student s Name: _____ Gender: M F Current School: _____ Grade: ____ Date of Birth: ___/____/_____ Parent s Names: _____ Address: _____ Email: _____ _____ Telephone: Home: (_____) _____ Cell: (_____) _____ Legal Guardian Status (check at least one) Biological Parents Adoptive Parents Family/Children Services ___ Biological Mother ___ Adoptive Mother Court (Specify) _____ ___ Biological Father ___ Adoptive Father Other (Specify) _____ Marital Status of Parents (check one) Married Single Married, living apart Divorced (check custody status) Joint Custody Sole Custody (Mother or Father- circle one) Does child have visitation with non-custodial parent?

☐ Abuse or domestic violence (this includes any abuse or violence the child has experienced as well as any the child has witnessed or is aware of within the home/family) ☐ Substance abuse (drug or alcohol) Please describe: _____ _____ DEVELOPMENTAL INFORMATION: Age …

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