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Social History
Identifying Information
Date: Click here to enter text.

Name: Click here to enter text.

Date of birth: Click here to enter a date.

SS#: 123-45-6789

Insurance provider: Click here to enter text.

Marital status: Click here to enter text.

Number of children: Click here to enter text.

Address: Click here to enter text.

Telephone number: Click here to enter text.

Age: Click here to enter text.

Race: Click here to enter text.

Height: Click here to enter text.

Weight: Click here to enter text.

Eye color: Click here to enter text.

Hair color: Click here to enter text.

Unusual markings (scars, birthmarks, tattoos): Click here to enter text.

Allergies: Click here to enter text.

Current medications: Click here to enter text.

Current medical problems: Click here to enter text.

Present Problems (immediate presenting problems)
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Previous Problems (past issues or concerns that could affect the client’s functioning)
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Family History
Spouse (click the “+” button in the lower right to repeat this field as needed) Name: SS#: 123-45-6789 Address: Phone: DOB: Marital status: Employment: Education level: Court record: Drug/alcohol issues: Mental health: Physical health:

Parents/StepParents (click the “+” button in the lower right to repeat this field as needed) Name: Parent type: SS#: 123-45-6789 Address: Phone: DOB: Marital status: Employment: Education level: Court record: Drug/alcohol issues: Mental health: Physical health:

Siblings (click the “+” button in the lower right to repeat this field as needed) Name: Type: Gender: DOB:

Sibling Interaction
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Other Close Relatives (click the “+” button in the lower right to repeat this field as needed) Type of Relative: Name:

Family Interaction
(Describe family dynamics/relationships, current issues, financial resources, needs, risks, etc.)

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Home and Neighborhood
(Describe type of home, adequacy of space, housekeeping standards, hazardous conditions, neighborhood description, etc.)

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Client’s Development
Early Developmental History
(Describe any problems during client’s mother’s pregnancy or delivery of client, planned/unplanned pregnancy, parental alcohol and drug use during pregnancy, developmental milestones, serious illnesses or accidents, diagnoses of ADHD or other.)

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Peer Interaction
(Describe relationships with peers, ages of friends, activities with friends, does or does not have friends.)

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Education
(Last school attended, grade level, major school problems, accelerated/remedial/special education, truancy history.)

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Employment
(Current employment, brief summary of past employment, terminations, promotions, problems on the job.)

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Psychological
(Current and past psychological exams, including name of examiner, location of testing, and test dates.)

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Agency Contacts and Sources of Information (List all other service providers and contact people. Click the “+” button in the lower right to repeat this field as needed.) Name: Relationship to client: Agency name: Address: Phone:

Preparer Information
Social history prepared by: Click here to enter text.

Date: Click here to enter a date.

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