Social History & Response Form
This form is to help gather information that our family advocates may use to better assist you and your family by connecting you to needed resources, and in discussing safety planning. These questions are voluntary. If you do not know the answer or if you feel uncomfortable answering you may leave the questions blank. If you have any questions please reach out to our Family Advocates for assistance.
Name *
Name of Child or Children with an appointment. *
How did you become aware of the allegations?
Has anything new been discovered since a report has been made?
How did you respond to your child when you heard about the allegations or disclosure?
Who lives in the child's home (or children's home)?
If you can, please include Names, Ages (if minors) and what their relationship is to the child.
Is there any history of abuse: sexual, physical, emotional, or domestic violence in the family? Are you a survivor of any form of child abuse?
Can you think of any other reason for the report, the disclosure, or the concerning behavior, that was reported? If you are coming to the center for an investigation of physical abuse: can you think of any other reason for the injury?
How is your child doing developmentally and socially? How are they doing in school? Do you they have an individualized education plan (IEP)?
Is your child(ren) currently in counseling services? If so, where?
Are you in counseling services? If so where?
If you haven't done so already, please provide your email address to stay up to date on available services and to connect with a family advocate.
Has your child had a medical exam in response to the investigation? If yes, where did you go? If not, would you like information on how to access a medical exam?
Do you need help finding any resources to help you during this time? What would be helpful for your family?
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This form was created inside of Voices for Children Advocacy Center. Report Abuse