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Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
I. CHILD DEMOGRAPHICSCHILD’S NAME: DOB: SSN: Ethnicity: Citizenship Status: Place of Birth: Sex: Religion:
II. INFORMATION ABOUT THE CHILD’S FAMILYA. Information about the birth parents and step-parents.
MOTHER
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Citizenship Status: Religion: Educational level: Occupation: Last Employer: Eye Color: Height: Hair Color: Weight:
Relationship history with child:
Physical description:
Ethnicity and description of ethnic backgrounds:
Religious background:
Personality description, special interests and talents:
Any additional work, professional achievement or educational information:
Military service if any:
Prior marriages and divorces:
Lifestyle and socio-economic status:
Criminal History: .
Page 1 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Physical Health: Current Health Status: Medical History: Genetic History: Developmental History:
Mental Health: Psychiatric and Psychological Evaluations: Social Evaluations: Intellectual Development:
FATHER
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Citizenship Status: Religion: Educational level: Occupation: Last Employer: Eye Color: Height: Hair Color: Weight:
Relationship history with child:
Physical description:
Ethnicity and description of ethnic backgrounds:
Religious background:
Personality description, special interests and talents:
Any additional work, professional achievement or educational information:
Military service if any:
Page 2 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Prior marriages and divorces:
Lifestyle and socio-economic status:
Criminal History: .
Physical Health: Current Health Status: Medical History: Genetic History: Developmental History:
Mental Health: Psychiatric and Psychological Evaluations: Social Evaluations: Intellectual Development:
B. Information about siblings (Make copies of this section as needed.)
SIBLING
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Relationship history with child:
Personality description, special interests and talents:
Ethnicity and description of ethnic backgrounds:
Religious background:
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Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Educational level:
Current Health:
Medical and genetic history:
Significant developmental histories:
Juvenile and/or criminal histories:
History of removal from the biological family (if applicable): .
SIBLING
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Relationship history with child:
Personality description, special interests and talents:
Ethnicity and description of ethnic backgrounds:
Religious background:
Educational level:
Current Health:
Page 4 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Medical and genetic history:
Significant developmental histories:
Juvenile and/or criminal histories:
History of removal from the biological family (if applicable): .
SIBLING
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Relationship history with child:
Personality description, special interests and talents:
Ethnicity and description of ethnic backgrounds:
Religious background:
Educational level:
Current Health:
Medical and genetic history:
Significant developmental histories:
Page 5 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Juvenile and/or criminal histories:
History of removal from the biological family (if applicable): .
SIBLING
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Relationship history with child:
Personality description, special interests and talents:
Ethnicity and description of ethnic backgrounds:
Religious background:
Educational level:
Current Health:
Medical and genetic history:
Significant developmental histories:
Juvenile and/or criminal histories:
History of removal from the biological family (if applicable): .
Page 6 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
ion as needed.)
Maternal Grandmother
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Ethnicity and description of ethnic backgrounds:
Religious background:
Relationship history with child and child's parent:
Identify significant life events:
Educational level and Work History:
Current Health:
Medical and genetic history:
Criminal History:
Last known address:
General Information:
Maternal Grandfather
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Page 7 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Ethnicity and description of ethnic backgrounds:
Religious background:
Relationship history with child and child's parent:
Identify significant life events:
Educational level and Work History:
Current Health:
Medical and genetic history:
Criminal History:
Last known address:
General Information:
Paternal Grandmother
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Ethnicity and description of ethnic backgrounds:
Religious background:
Relationship history with child and child's parent:
Page 8 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Identify significant life events:
Educational level and Work History:
Current Health:
Medical and genetic history:
Criminal History:
Last known address:
General Information:
Paternal Grandfather
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Ethnicity and description of ethnic backgrounds:
Religious background:
Relationship history with child and child's parent:
Identify significant life events:
Educational level and Work History:
Current Health:
Page 9 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Medical and genetic history:
Criminal History:
Last known address:
General Information:
C. Information about other relatives Other Relatives
Name: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Ethnicity and description of ethnic backgrounds:
Religious background:
Relationship history with child and child's parent:
Identify significant life events:
Educational level and Work History:
Current Health:
Medical and genetic history:
Criminal History:
Last known address:
Page 10 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
General Information:
Other RelativesName: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Ethnicity and description of ethnic backgrounds:
Religious background:
Relationship history with child and child's parent:
Identify significant life events:
Educational level and Work History:
Current Health:
Medical and genetic history:
Criminal History:
Last known address:
General Information:
Page 11 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Other RelativesName: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Ethnicity and description of ethnic backgrounds:
Religious background:
Relationship history with child and child's parent:
Identify significant life events:
Educational level and Work History:
Current Health:
Medical and genetic history:
Criminal History:
Last known address:
General Information:
Other RelativesName: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Page 12 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Ethnicity and description of ethnic backgrounds:
Religious background:
Relationship history with child and child's parent:
Identify significant life events:
Educational level and Work History:
Current Health:
Medical and genetic history:
Criminal History:
Last known address:
General Information:
D. Information about significant fictive kin relationships or other past caregivers
Fictive Kin/Other CaregiverName: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Ethnicity and description of ethnic backgrounds:
Religious background:
Page 13 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Relationship history with child and child's parent:
Identify significant life events:
Educational level and Work History:
Current Health:
Medical and genetic history:
Criminal History:
Last known address:
General Information:
Fictive Kin/Other CaregiverName: Relationship: Sex: Nationality: DOB: Place of Birth: Date of Death: Age at Death: Cause of Death: Eye Color: Height: Hair Color: Weight:
Ethnicity and description of ethnic backgrounds:
Religious background:
Relationship history with child and child's parent:
Identify significant life events:
Educational level and Work History:
Page 14 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
Current Health:
Medical and genetic history:
Criminal History:
Last known address:
General Information:
III. INFORMATION ABOUT THE CHILDA. Birth Information:
Place of Birth: Weight at Birth: Other Birth Information:
Time of Birth: Length at Birth:
B. Description of Child
1. Physical Description:
2. Personality Description:
3. Routines and daily time schedules:
4. Sexual Development:
C. Cultural background:
D. Child Characteristics currently identified:
Page 15 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
E. Health:1. Current Health Status:
Exam Date Name of Doctor Description of Problem(s) Noted
Last Physical Exam Last Dental Exam
2. A record of current immunizations: Yes No .
3. A history of the child’s physical development:a. Medical and Genetic History: .
b. Dental History:
c. Feeding difficulty:
d. Special Needs:
e. Developmental milestones
f. Health history:
g. Allergies:
F. Summary of Development1. Educational history:
2. Psychological history:
3. Intellectual development. .
G. Behavior and discipline:
H. Juvenile delinquency history:
I. Interpersonal relationships:1. The child’s way of relating to others:
2. The child’s past and existing relationships with:
a. His biological family (including members of his extended family).
b. The foster family, caretakers, and other persons who have had physical possession of or legal access to the child.
c. Significant others such as teachers and friends.
3. How the child handled separation from and loss of the biological family and other significant persons:
Page 16 of 17
Texas Dept of Family and Protective Services
HEALTH, SOCIAL, EDUCATIONAL AND GENETIC HISTORY Form 2649April 2012
J. Adjustment: 1. Chronological history of previous placements and reasons for changes in placements:
2. The child’s reaction to and understanding of the placement changes
K. Abuse or neglect:
Date Allegation(s) Disposition
L. Information about removal of the child:1. Removal.
2. Relinquishment
3. Current Legal Status: Date:
M. Signatures
1. HSEGH CONTRACTED? YES NO IF YES, COMPLETE CONTRACTOR/BROKER SIGNATURES
CONTRACTOR/BROKER SIGNATURES:
Signature: Type Name of HSEGH Preparer, Credentials DATE
Signature: Type Name of Home Broker CPMS, Credentials DATE
2. CHILD PROTECTIVE SERVICES SIGNATURES (REQUIRED):
Signature: Type Name of CPS Worker with Title DATE
Signature: Type Name of CPS Supervisor, Title DATE
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