SCHOOL SOCIAL WORK REPORT - Wisconsin Department of …
SCHOOL SOCIAL WORK REPORT
SOCIAL HISTORY
Date: Student Name:
Interviewer:
Setting: 1) home 2) school 3) other - specify
Family members present:
Purpose of collecting social history: 1) IEP 2) open case
SIGNIFICANT HOME FACTORS:
mothers name:
date of birth:
born/raised:
highest level of education:
employment:
work hours:
relationship with child:
father’s name:
date of birth:
born/raised:
highest level of education:
employment:
work hours:
relationship with child:
marital status:
siblings/ages/relationships:
other people living in the home:
other significant people in the child’s life:
child care arrangements:
sources of income:
DEVELOPMENTAL:
Any problems during pregnancy?
Prenatal care?
Alcohol, drug use, stress during pregnancy?
Any complications during labor or delivery?
Full term? Birth weight?
Did the baby come home with you from the hospital?
Milestones:
sat up:
crawled:
walked:
talking:
toilet training:
sleeping habits:
eating habits:
self care/hygiene habits:
MEDICAL:
general health:
current doctor/clinic:
insurance/HMO/MA:
fevers of 105 or greater:
ever lost consciousness/head injuries:
major accidents or injuries:
operations/hospitalizations:
present or past illnesses/infections:
ear infections/tubes:
current medication:
previous medications:
allergies:
vision concerns: Glasses:
last eye exam:
hearing concerns: Hearing test:
dental concerns:
Lead exposure:
BEHAVIORAL/EMOTIONAL FACTORS
Describe your child’s behavior/personality:
Describe your child emotionally:
What types of responsibilities does your child have at home:
How are these tasks completed: (with cooperation/resistance/reminders)
What types of discipline works with your child:
What does your child enjoy doing for play time:
What are your child/strengths:
What concerns do you have about your child/weaknesses:
LIFE EVENTS/STRESSES: (separation, divorce, financial stress, moving, abuse, medical concerns, deaths)
SIGNIFICANT SCHOOL FACTORS:
daycare experience:
preschool experience:
does your child talk about school at home:
what does s/he say:
does your child talk about friends at school:
any difficulty getting your child to attend school:
any school related problems that have been reported to you:
has anyone else in the family had difficulties in school:
concerns about child’s learning:
SIGNIFICANT COMMUNITY FACTORS:
Describe your child’s friendships in the neighborhood:
Does you child seek out friendships with peers:
Is your child sought out by peers:
What age are the children your child usually plays with:
Ever had any problems reported to you in the community:
Have you noticed any problems in the community:
Behavior in stores/restaurants:
Is your child involved with any community organizations:
Is your family involved with any community agencies:
who is the contact person:
Any questions about the evaluation:
Are you planning to attend:
Janelle Peotter-Webber, SSW
Green Bay Public Schools
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