Social history template- working with individuals

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

DOB:
Marital status:
Click here to enter text.
Employment:
Click here to enter text.
Education level:
Click here to enter text.
Court record:
Click here to enter text.
Drug/alcohol issues:
Click here to enter text.
Mental health:
Click here to enter text.
Physical health:
Click here to enter text.
Siblings
(click the “+” button in the lower right to repeat this field as needed)
Name:
Click here to enter text.
Type:
Gender:
Click here to enter text.
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:
Click here to enter text.
Name:
Click here to enter text.
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: 

Click here to enter text.

Relationship to client: 

Click here to enter text.

Agency name: 

Click here to enter text.

Address: 

Click here to enter text.

Phone: 

Click here to enter text.

Preparer Information

Social history prepared by: 

Click here to enter text

Date

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