CHILD LIFE HISTORY NARRATIVE
CHILD LIFE HISTORY NARRATIVE
Child's Name:
DOB:
|Sex: |Race: Ethnicity: |
|Social Security Number: |Place of Birth: |
|Citizenship Status: |Religion: |
|Eye Color: |Height: |
|Hair Color: |Weight: |
|I. Child's Description, Personality and Current Functioning: Include child’s physical appearance, origin of child's name and the name the child is |
|currently known by, child’s personality using behavioral descriptors (interaction with peers and adults, what child does best, what is special |
|about child, what does the child perceive as his/her best qualities, activities in which the child participates), and current functioning of the |
|child (child's current physical, emotional, cognitive and social level using specific behavior descriptors to show age appropriate or developmental|
|lags, level at which child is functioning in terms of self care, communication, and visual and motor skills and how these abilities affect his/her|
|daily living, specific special needs of child, services given to overcome developmental delays and progress, and child's behavior that are most |
|rewarding and most annoying to the foster parent). |
|II. Medical History: Include child's delivery, PKU, VDRL, HIV results, prenatal care, drug or alcohol use during pregnancy, specialists care, |
|hospitalizations, medication history, significant doctor's visits, dental history, and immunization records. Include medical history before child |
|came in care. (attach records) |
|II. Developmental History: Include history of major developmental milestones (i.e. age first sat alone, crawled, pulled up, walked, first word, |
|first sentence, first tooth, toilet trained, weaned) in the child's life and the ages at which they occurred, testing and assessments, delays, |
|and functioning. (attach reports) |
|IV. Psychological/Psychiatric History: Include the results of previous psychiatric and/or psychological evaluations, reasons progress and prognosis|
|of psychiatric hospitalizations, medications, placement implications and child's ability to be self-sufficient, and self supporting as an adult. |
|(attach reports) |
|V. School Experiences/Day Care: Include child’s grade and academic functioning, favorite and least favorite subjects, the results of educational |
|and standardized testing, number of schools attended, adjustment to new schools, problems and methods of handling, ever been retained and what |
|grade, relationship with peers and staff, and all special educational needs and services/adjustment. (attach records) |
|VI. Placement History: Include age at initial placement and child's understanding, age at subsequent placement(s) or moves, reason(s) for any |
|change(s) in placement, reaction of child to changes in placement, ability of child to adjust and attach to new nurturing figures, and attachment |
|to current foster family. |
|VII. Birth Family History: presenting problems at initial contact, summary of activities, services given and actions taken throughout birth family |
|contact with agency (efforts of reunification including strengths and weaknesses of family that affected family unity, general living conditions, |
|management of home and adequacy of the physical facility, adequacy of care and training of child), degree of family's involvement in school, church|
|and neighborhood activities, economic and social status of family, their feelings regarding their status, attitudes of family toward placement and |
|the possible effects on each member of the family, quality of nurturing; trust and attachment level of family members, attachment of the child to |
|each immediate family member, relatives outside immediate family and their significance to child, relationships of each parent to the child and the|
|interactions between them, relationships of siblings and the interaction between siblings, explanation about siblings placed separately, family's |
|willingness and ability to assist child in separation from them, and family's desire regarding contact when child reaches twenty-one. (attach Form |
|553 or 561) |
|VIII. Child's Readiness for Adoption: Include if Life Book has been completed, explanation why Life Book has not been completed, child's |
|understanding and feelings around being placed for adoption, how much and what type preparation this child needs to be ready to move into an |
|adoptive home, contact with foster family need to be maintained, will foster family be able to assist child in moving into adoptive home, |
|description of family needed by this child, special qualities, skills and resources a family must possess to parent this child, behaviors that |
|family needs to be prepared to deal with when child placed, if there is no adoptive resources identified described child's specific recruitment |
|plan, and resources needed and length of time estimated for child to be emotionally ready to move into adoptive placement. |
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|Note: Following forms should be attached with this narrative: Form 400, Form 432, Form 419, Siblings Waiver (if applicable), Birth Certificate |
|(long form), TPR Court Orders/Voluntary Surrender on each parent, Death Certificate of Parents (if applicable), Divorce Verification (if |
|applicable), Putative Father Registry Form, Form 149, Form 150, Form 151 and Indian Child Welfare Documentation (if applicable). |
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|Case Manager: |Date: |
| County DFCS |
|Telephone: |
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