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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.
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Name
*
Your answer
Name of Child or Children with an appointment.
*
Your answer
How did you become aware of the allegations?
Your answer
Has anything new been discovered since a report has been made?
Your answer
How did you respond to your child when you heard about the allegations or disclosure?
Your answer
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.
Your answer
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?
Your answer
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?
Your answer
How is your child doing developmentally and socially? How are they doing in school? Do you they have an individualized education plan (IEP)?
Your answer
Is your child(ren) currently in counseling services? If so, where?
Your answer
Are you in counseling services? If so where?
Your answer
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.
Your answer
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?
Your answer
Do you need help finding any resources to help you during this time? What would be helpful for your family?
Your answer
Has anything fun or positive happened recently that your child would be excited to talk about when here?
This may help them feel more comfortable during their appointment.
Your answer
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