Social History Template
whie.p
SocialHistory.docxSocial 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)
Click here to enter text.
Previous Problems (past issues or concerns that could affect the client’s functioning)
Click here to enter text.
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
Click here to enter text.
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.)
Click here to enter text.
Home and Neighborhood
(Describe type of home, adequacy of space, housekeeping standards, hazardous conditions, neighborhood description, etc.)
Click here to enter text.
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.)
Click here to enter text.
Peer Interaction
(Describe relationships with peers, ages of friends, activities with friends, does or does not have friends.)
Click here to enter text.
Education
(Last school attended, grade level, major school problems, accelerated/remedial/special education, truancy history.)
Click here to enter text.
Employment
(Current employment, brief summary of past employment, terminations, promotions, problems on the job.)
Click here to enter text.
Psychological
(Current and past psychological exams, including name of examiner, location of testing, and test dates.)
Click here to enter text.
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.
