Social History Template- Working with Individuals

 

Date

:

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.

Name:
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Date of birth:
SS#:
123-45-6789
Insurance provider:
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Marital status:
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Number of children:
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Address:
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Telephone number:
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Age:
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Race:
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Height:
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Weight:
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Eye color:
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Hair color:
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Unusual markings (scars, birthmarks, tattoos):
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Allergies:
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Current medications:
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Current medical problems:
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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:
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SS#:
123-45-6789
Address:
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Phone:
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DOB:
Marital status:
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Employment:
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Education level:
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Court record:
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Drug/alcohol issues:
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Mental health:
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Physical health:
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Parents/StepParents
(click the “+” button in the lower right to repeat this field as needed)
Name:
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Parent type:
SS#:
123-45-6789
Address:
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Phone:
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DOB:
Marital status:
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Employment:
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Education level:
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Court record:
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Drug/alcohol issues:
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Mental health:
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Physical health:
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Siblings
(click the “+” button in the lower right to repeat this field as needed)
Name:
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Type:
Gender:
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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:
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Name:
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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: 

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Relationship to client: 

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Agency name: 

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Address: 

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Phone: 

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Preparer Information

Social history prepared by: 

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Date