Rocky Point UFSD Social-Development History Questionnaire

Dear Parent/Guardian

As part of our 2025-2026 Kindergarten Screening process, we ask that you complete the following questions related to your child's social-development history. Please complete this questionnaire prior to your child's Kindergarten screening appointment.

Please allocate approximately 20 minutes to complete this questionnaire in its entirety.

If you have any questions regarding this questionnaire, please contact the FJC main office at 744-1600, Ext. 7200 between the hours of 9:30 AM and 12:30 PM daily.

Thank you.

Rocky Point UFSD

Part 1: General Information

Child's First Name *

Child's Last Name *

Child's Date of Birth * +

Languages Spoken at Home *

Person providing information (name & relationship to child) *

E-mail of person providing information (name & relationship to child) *

Who does the child live with (please list all names and kindly include ages when listing other children)? *

Parent #1 Name *

Parent #1 Occupation *

Parent #2 Name *

Parent #2 Occupation *

Parents are: *

If separated/divorced, who has legal custody? How has your child adjusted to the separation/divorce? *

Have there been any significant changes in the home over the last few years? (such as new marriage, death, birth of a sibling, address change, etc.) *

Part 2: Health and Development

Has your child experienced any health problems, such as serious illness, surgery/hospitalization, allergies/asthma, etc.? If so, please explain. *

If applicable, please list any medications your child uses, as well as their uses. *

Has your child ever been identified as having a disability? If so, by whom/what age/what disability? *

Has your child ever received educational or therapy services from a private entity? (ie speech, counseling, occupational therapy, special class, etc.) *

Has your child ever participated in an early intervention program? If so, by whom and when? *

Is there a family history of learning difficulties, speech/language problems, developmental disorder, or emotional concerns? If so, please explain. *

Part 3: Behavior

On a regular basis, does your child display any of the following behaviors/characteristics? (select as many as apply) *

Is there anything listed above that we should know more about? *

What are your child's greatest strengths and weaknesses? *

Part 4: Home Behavior

How would you describe your child's personality at home? *

How does your child get along with siblings/cousins/friends? *

What is the most effective way to deal with your child's behavior at home (i.e. talking, positive reinforcement, reward system)? *

How does your child respond to discipline if needed? *

How much time does your child spend on electronic media on a daily basis? *

Part 5: Educational History

Preschool experience? Yes/No *

If applicable, please specify the name of the preschool attended.

How does your child feel about school? *

Please share anything else you think may be helpful in making your child's school experiences successful. *

Parent/Guardian Signature *

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