Student Name: __________________________________________
CASE HISTORY FOR INITIAL ACADEMIC/BEHAVIOR REFERRAL
(SAT Form Academic CH)
Families, please complete ALL information on this form:
Date:______________________________ Student Name: __________________________ Home Phone: ________________________
Date of Birth: _________________________ Student ID: ___________________
Home Address: _______________________________________Name of person completing this form: _______________________________
Relationship to the student: ____________________Parent(s)/Guardian(s): ___________________________________________________
Home Address: _____________________________________________________________________________________
Mailing Address: ____________________________________________________________________________________
Work Phone: ________________________ Cell Phone: ______________________ Emergency Phone: ___________________________
The following questions concern your child’s development and function within your family. Your answers will
provide us with information as part of the comprehensive, confidential evaluation. This will be useful in
understanding factors that have had an influence on your child’s growth and achievement in school. Thank
you for your cooperation in completing this form.
Family Information
With whom does the child live: ________________________________________________________________________
Name(s) of Legal Guardian(s): _________________________________________________________________________
Is your child adopted? ☐Yes ☐No Is this child in foster care placement? ☐Yes ☐No
Marital status of parents: ____________________________ Age of child when separation occurred: ________________
Mother/Guardian
Father/Guardian
Name
Occupation
Highest grade completed
Cell Phone
Work Phone
Home Phone
Alternate Phone
How many children in family household: ____________________Ages of children: ____________________________________________
Are there any brothers or sisters not living at home? Please list ages:____________________________________________________
Are there any other adults in the home? What is their relationship to your child?________________________________________
Please check if either of this child’s natural parents, or immediate family members, experienced any of the
following, which could have contributed to your child’s school difficulties:
SAT Form Academic CH
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Student Name: __________________________________________
☐alcohol addiction
☐psychological / psychiatric evaluation
☐drug addiction
☐seizures
☐learning disabilities / problems
☐speech or language disorder
☐mental illness
☐violence / abuse
☐mental retardation
☐physical disability
☐other special education disabilities
☐other, please explain ___________________________________________
Please add details for any marked area:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
What concerns do you have about your child’s education?
____________________________________________________________________________________________________________________________________
Any other information or concerns you want to share with your child’s school team?
____________________________________________________________________________________________________________________________________
Has your child ever received Special Education services or Early Childhood Intervention Programming such as
Head Start? ______________________________________________________________________________________________________________________
Medical/Developmental/Health Information (Parents/Guardians have the right not to disclose medical
information.)
Prenatal/Infancy/Delivery History
Mother’s age at child’s birth: ______________ Father’s age at child’s birth ________________
☐Yes ☐No Did the mother visit doctor regularly during pregnancy?
☐Yes ☐No Was there any difficulty during the pregnancy? If yes, please explain
____________________________________________________________________________________________________________________________________
☐Yes ☐No Did the mother take medication during pregnancy? If yes, please explain
____________________________________________________________________________________________________________________________________
☐Yes ☐No Did the mother receive anesthesia during delivery?___________________________________________________________
☐Yes ☐No Did the mother smoke during pregnancy? If yes, how much _________________________________________________
☐Yes ☐No Did mother use alcohol during pregnancy? If yes, how much ________________________________________________
☐Yes ☐No Did mother use drugs during pregnancy? If yes, please explain
____________________________________________________________________________________________________________________________________
Length of pregnancy _______ weeks
Length of labor _________ hours
☐Yes ☐No Any difficulty during delivery? If yes, please explain
____________________________________________________________________________________________________________________________________
Birth
☐Yes ☐No Any complications? (cyanosis, meconium, cord compression, etc.) If yes, please explain _______________
_________________________________________________________________________________________________________________________________
☐Yes ☐No Trauma to infant? (lack of oxygen, life support, heart problems) If yes, please explain ________________
SAT Form Academic CH
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Student Name: __________________________________________
_________________________________________________________________________________________________________________________________
☐Yes ☐No Any birth defects? If yes, please explain
____________________________________________________________________________________________________________________________________
☐Yes ☐No Was there jaundice? If yes, please explain ______________________________________________________________________
☐Yes ☐No Was child released from hospital with mother? If no, please explain ________________________________________
____________________________________________________________________________________________________________________________________
Birth weight ________lbs. ______ oz.
☐Yes ☐No Any difficulties during infancy? If yes, please explain _________________________________________________________
____________________________________________________________________________________________________________________________________
☐Yes ☐No Were there any episodes of seizures? If yes, please explain __________________________________________________
____________________________________________________________________________________________________________________________________
☐Yes ☐No Was there Anoxia (lack of oxygen)? If yes, please explain ____________________________________________________
____________________________________________________________________________________________________________________________________
☐Yes ☐No Was there use of life support systems? If yes, please explain _________________________________________________
____________________________________________________________________________________________________________________________________
☐Yes ☐No Did the child gain weight consistently during the first year of life? If no, please explain ___________________
____________________________________________________________________________________________________________________________________
Developmental History
Please estimate age of attainment for the following milestones:
Said first word ________
First fed him/her self _________
Said first sentence _________
Tied shoes _________
Dressed him/herself alone _________
First sat alone _________
Buttoned shirt _________
First walked _________
Toilet trained _________
Learned to ride bike _________
Speech and Language Development Please check any areas of concern:
_____Articulation – how your child says his/her speech sounds
_____Fluency – how smoothly your child’s words flow when he/she speaks
_____Voice – how your child’s voice sounds (hoarse, breathy, raspy, etc.)
_____Language – understanding information, vocabulary, sentence structure, grammar
Please answer the following questions:
YES
NO
Can your child explain when something is wrong?
___
___
Does your child interact with people outside your family?
___
___
Does your child talk about events from the day, stories, movies, etc.?
___
___
Does your child ask questions to get information?
___
___
Does your child get frustrated when telling you something?
___
___
Can your child follow simple directions?
___
___
SAT Form Academic CH
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Student Name: __________________________________________
Can your child follow complex, multi-step directions?
___
___
Can your child answer who, what, why, and where questions?
___
___
Do you or others have difficulty understanding your child?
___
___
Are your child’s speech or language skills similar to those of siblings/friends?
___
___
Please describe any concerns you have with your child’s speech or language skills:______________________________________
____________________________________________________________________________________________________________________________________
How do you feel your child’s communication skills affect how he/she does in school?___________________________________
___________________________________________________________________________________________________________________________________
Are there any significant factors in your child’s health history (health, social, developmental) that may be affecting
his /her communication skills at this time? Please describe:________________________________________________________________
____________________________________________________________________________________________________________________________________
Medical History and Concerns
Describe your child’s current health status___________________________________________________________________________________
Does your child have any chronic or ongoing health problems?____________________________________________________________
If yes, please explain____________________________________________________________________________________________________________
Does your child have a medical diagnosis? If yes, please explain___________________________________________________________
When was your child’s last physical exam?___________________________________________________________________________________
Does your child take medication? If so, what and how much? (Include herbal and over-the-counter medications).
____________________________________________________________________________________________________________________________________
Who prescribes these medications?___________________________________________________________________________________________
Does your child have a prescription for eyeglasses?__________________ Does he/she wear them?__________________________
When was your child’s last eye exam?_________________________________________________________________________________________
Does your child need hearing aids?____________________________ If yes, does he/she wear them?____________________________
When was your child’s last hearing exam?____________________________________________________________________________________
How is your child’s coordination? Fine motor (i.e., picking up small objects)______________________________________________
Gross motor (i.e., walking, riding a bike)_________________________________________________
Does your child have bladder/bowel control problems (explain)?_________________________________________________________
Have there been recent changes in your child’s health?_____________________________________________________________________
Has your child experienced any of the following:
SAT Form Academic CH
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Student Name: __________________________________________
Syndromes
√ If
Yes
Down’s Syndrome
Trisomy 13
Usher’s
Other Syndrome
Postnatal
Asphyxia
Encephalitis
Head Injury
Meningitis
Stroke
Other Postnatal
Prenatal
Dysfunctions
Herpes
Rubella
Syphilis
Toxoplasmosis
Other Prenatal
Condition
Multiple Congenital
Anomalies
CHARGE Syndrome
Fetal Alcohol Syndrome
Hydrocephaly
Maternal Drug Use
Microcephaly
Other Multiple Anomaly
Other Illness or Conditions
High Fever
Convulsions
Seizures
Scarlet Fever
Rheumatic Fever
Tuberculosis
Frequent/Severe Headaches
Dizziness
Fainting Spells
Cancer
Asthma
√ If
Yes
Other Illness or
Conditions
Anemia
Bleeding Problems
Diabetes
Heart Disease/Condition
High Blood Pressure
Loss of Consciousness
Extreme Tiredness
Paralysis
Bone or Joint Disease
Eating Problems
Sleeping Problems
Eye Problems
√ If
Yes
Memory Problems
Ear Infections
Tubes in Ears
Allergies
Loss of Consciousness
Extreme Tiredness
Additional comments or explanations ________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Child’s Daily Life and Social Skills
What is his/her after school, evening and bedtime routine? ________________________________________________________________
____________________________________________________________________________________________________________________________________
What favorite interests, skills or hobbies does your child enjoy? ___________________________________________________________
What are your child’s reading interests?______________________________________________________________________________________
Has anything changed in the home or school or in your child’s life that might be causing your child stress? Please
explain:___________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
How does she/he get along with parents and siblings?______________________________________________________________________
Describe your child’s choices in friends (age, gender, groups) ______________________________________________________________
____________________________________________________________________________________________________________________________________
What are your child’s responsibilities at home?____________________________________________________________
Language Background
SAT Form Academic CH
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Student Name: __________________________________________
What language(s) are spoken in your home? _________________________________________________________________________________
What language did your child first learn to speak?___________________________________________________________________________
When did your child begin to learn a second language?_____________________________________________________________________
In what language does your child: Speak at home? ___________________________Watch TV?___________________________________
Sing/listen to music?______________________Read/Write?_________________________________
How well can other people understand his/her pronunciation of words in the first language?__________________________
How well can other people understand his/her pronunciation of words in the second language?______________________
Has your child participated in programs to learn a second language (ESL, bilingual classes, Dual Language, etc.)? If
so, what program?_______________________________________What language?_____________________________________________________
How long did your child participate in a second language program?_______________________________________________________
If your child is no longer in a second language program, please explain why______________________________________________
____________________________________________________________________________________________________________________________________
Does your child interpret for any family members?__________If yes, please describe_______________________________________
____________________________________________________________________________________________________________________________________
Behavior and Attention Span
Can your child complete homework on their own or do they need help? __________________________________________________
If she/he needs help with their homework, how much help do they need?________________________________________________
If your child does not have any homework, does she/he work on anything school related (i.e. reading, educational
websites, etc.)?__________________________________________________________________________________________________________________
Does your child begin their homework willingly or do they resist getting started?_______________________________________
How long does your child remain focused on a task which she/he enjoys (i.e., watching TV, playing a game, etc.)?
____________________________________________________________________________________________________________________________________
What is your child’s general mood at home?__________________________________________________________________________________
What upsets your child?________________________________________________________________________________________________________
What does she/he worry about?_______________________________________________________________________________________________
Have there been any recent changes in behavior (eating, sleeping, attitude, mood, etc.) _________________________________
____________________________________________________________________________________________________________________________________
Have there been any recent changes in your child’s life that may be causing them stress? ______________________________
SAT Form Academic CH
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Student Name: __________________________________________
____________________________________________________________________________________________________________________________________
Please check those items that describe your child:
☐Experiences excessive sadness
☐Often becomes angry
☐Gets along well with others
☐Frustrates easily
☐Has a poor attention span
☐Has a good self-image
☐Has made suicide threats
☐Has a poor memory
☐Has temper tantrums
☐Has mood swings
☐Is aggressive
☐Is affectionate
☐Lies
☐Is withdrawn
☐Steals
☐Participates in family activities
☐Acts without thinking
☐Participates in community activities (clubs, church, etc.)
Is there any other information you would like to share about your child’s behavior and attention span?
___________________________________________________________________________________________________________________________________
Educational History – please list ALL schools your child has attended and describe any difficulties or enrichment
she/he received.
Schools Attended
Grade
Problems or Progress
Help or Program Provided
Has your child repeated or accelerated any class or grade? _________________________________________________________________
What helps your child to learn best? __________________________________________________________________________________________
Have other members of the family had communication, learning, or behavior difficulties?______________________________
____________________________________________________________________________________________________________________________________
What agencies or mental health professionals have worked with or have evaluated your child? _______________________
____________________________________________________________________________________________________________________________________
Check if your child has attended or received services at one of the following:
____Preschool
____Private School
____Agency (TOTS, MECA, etc.)
____Head Start
____Day Care
____Other______________________________
____Home School
____Tutor (describe_______________________________________________________)
SAT Form Academic CH
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Student Name: __________________________________________
How would you describe your child?__________________________________________________________________________________________
What are your child’s strengths?_______________________________________________________________________________________________
What concerns do you have about your child’s development and progress in school?____________________________________
____________________________________________________________________________________________________________________________________
What do you see for your child as they become an adult? ___________________________________________________________________
____________________________________________________________________________________________________________________________________
Is there any other information you would like us to know to better understand your child? (please use the back of
this page if you need more space to write) ___________________________________________________________________________________
SAT Form Academic CH
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