Social and Developmental History Date: School: ID#: Grade: The following information is considered confidential. Please answer all questions as well as you can. Identifying Information Child’s name: Date or birth and current age: DOB: Age: Gender and race: Gender: Race: Person completing form: Name: Do you have legal custody? Yes No Family Information Street address: Apt/lot #: Home address: City: State: Zip code: County: Phone number(s) and email address: Home: Cell: Work: Email address: Biological Parents or Guardian Information Parent/Guardian Age: Education: Occupation: Female name: Work title: Employer: Relationship: Lives in the home? Yes No Biological Mother Step-Mother If not biological mother: Adoptive Mother Grandmother Age: Education: Occupation: Other relative Unrelated Work title: Employer: Age: Education: Occupation: Male name: Work title: Employer: Relationship: Lives in the home? Yes No Biological Father Step-Father If not biological father: Adoptive Father Grandfather Age: Education: Occupation: Other relative Unrelated Work title: Employer: The child is: Natural Adopted Other The child’s parents are: Married Divorced Separated Never married
Social and Developmental History Date: School: ID#: Grade: The following information is considered confidential. Please answer all questions as well as you can. Identifying Information Child’s name: Date or birth and current age: DOB: Age: Gender and race: Gender: Race: Person completing form: Name: Do you have legal custody? Yes No Family Information Home address: Street address: Apt/lot #: City: State: Zip code: County: Phone number(s) and email address: Home: Cell: Work: Email address: Biological Parents or Guardian Information Parent/Guardian Female name: Relationship: Biological Mother Step-Mother Adoptive Mother Grandmother Other relative Unrelated Male name: Relationship: Biological Father Step-Father Adoptive Father Grandfather Other relative Unrelated Age: Education: Occupation: Work title: Employer: Lives in the home? Yes No If not biological mother: Age: Education: Occupation: Work title: Employer: Age: Education: Occupation: Work title: Employer: Lives in the home? Yes No If not biological father: Age: Education: Occupation: Work title: Employer: The child is: Natural Adopted Other The child’s parents are: Married Divorced Separated Never married