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Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 1 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

S o c i a l H i s to r y

( Fo r M R R C a n d Ac q u i r e d B r a i n In ju r y)

Today’s Date:___ / ___ / ____

	MM	DD	YYYY
1. Applicant’s Personal Information
*Applicant’s First Name				Applicant’s Middle Name			*Applicant’s Last Name

Nick Name				*Birth date			Email Address

Social Security Number				Height			Weight

Is the Applicant Home Bound?				Applicant’s Primary way of communicating			Applicant’s Primary Language.
Yes	No			Speak	Other:_________________

Country the Applicant was born in:				Is the Applicant a US Citizen?			Does the Applicant Understand English?
USA	Other:____________________			Yes	No		Yes	No

Ethnicity				Race
Hispanic/Latino		Yes	No	American Indian/Alaska Native			Black or African American			Asian
				Native Hawaiian or Other Pacific Islander					White	Other
2. Applicant’s Physical Address
*Address

*City				*State		*County			*Zip

3. Applicant’s Mailing Address (if different)
*Address

*City				*State		*County			*Zip

4. Applicant’s Telephone Number(s)
Home Telephone				Work Telephone			Mobile/Cell Telephone

5. Applicant’s Birth

•

What was the Mother’s age when the Applicant was born? ___________
How long was the active labor (in hours)? _________________
What was the Applicant’s birth weight? __________
Was the Mother ill during the pregnancy?	Yes	No
Was miscarriage threatened during the pregnancy?	Yes	No
Were any medical procedures performed during the pregnancy?	Yes	No
Was any anesthetic used during the delivery?	Yes	No
Were any postnatal complications encountered?	Yes	No

What kind of delivery occurred (e.g. normal, breach, C-section, etc.)? __________

General comments: ____________________________________________________________________________________

____________________________________________________________________________________

Did the Mother use any drugs during the pregnancy with the applicant? Yes	No
If so, list them along with the frequency of use:

____________________________________________________________________________________________________

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 2 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

6. Applicant’s Childhood Milestones

Please identify the ages when the Applicant successfully achieved the following developmental milestones

Age First Sat Up (in months) _________	Age First Toileted (in months) __________	Age First Walked (in months) __________

Age First Talked (in months) _________________

7. Applicant’s Education History

• Age Started School: _________________
• Highest Grade Completed: ___________
•	Years Completed: __________________
•	Is the Applicant leaving the Public School System? Yes	No	If yes, when? __________________

•Special School Related Achievements:_______________________________________________________________

______________________________________________________________________________________________

List Each School the Applicant Attended (please list the most recent school first).

Name of	*Type of School	School	Name of	Date	Date		In	Comments
School	(Elem., Jr./ Middle	Phone #	School	Started	Ended	Special
	School, High		Contact				Ed?
	School, College)		Contact
	School, College)
						Y	N

						Y	N

						Y	N

						Y	N

						Y	N

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 3 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

8. Applicant’s Employment History

	Has the Applicant ever received Supported Employment through Vocational Rehab? Y							N
	If so, what year did Applicant receive Vocational Rehab services? _____________
+
	(Please list the Applicant’s most recent job first)
Employer			Avg. Hours/Wk		Most Recent		Nature of Work:		Start Date	End
					Hourly Wage					Date
							฀ Paid, with benefits
							฀ Paid, without benefits
							฀ Volunteer/Unpaid
Job Title/Description:

			Type of Employment (please check one):

	฀	Integrated Employment – Individual (e.g. Applicant holds/held own job in the community)

	฀	Integrated Employment – Work Crew (e.g. Applicant holds/held job in the community as part of a work crew)
	฀	Facility-Based (i.e. participated in a sheltered workshop, work activity, etc.)
Work Related Issues (i.e. problems with reliability, other employees, employer, etc.):

Work-related successes, special skills, etc.:

Level of Satisfaction with Job (please circle): 1-Not Satisfied				2-Fairly Satisfied		3-Satisfied 4-Extremely Satisfied


Employer			Avg. Hours/Wk		Most Recent		Nature of Work:		Start Date	End
					Hourly Wage					Date
							฀ Paid, with benefits
							฀ Paid, without benefits
							฀ Volunteer/Unpaid
Job Title/Description:

			Type of Employment (please check one):

	฀	Integrated Employment – Individual (e.g. Applicant holds/held own job in the community)
	฀	Integrated Employment – Work Crew (e.g. Applicant holds/held job in the community as part of a work crew)
	฀	Facility-Based (i.e. participated in a sheltered workshop, work activity, etc.)

Work Related Issues (i.e. problems with reliability, other employees, employer, etc.):

Work-related successes, special skills, etc.:

Level of Satisfaction with Job (please circle): 1-Not Satisfied				2-Fairly Satisfied		3-Satisfied 4-Extremely Satisfied


Employer			Avg. Hours/Wk		Most Recent		Nature of Work:		Start Date	End
					Hourly Wage					Date
							฀ Paid, with benefits
							฀ Paid, without benefits
							฀ Volunteer/Unpaid
Job Title/Description:

			Type of Employment (please check one):

	฀	Integrated Employment – Individual (e.g. Applicant holds/held own job in the community)

	฀	Integrated Employment – Work Crew (e.g. Applicant holds/held job in the community as part of a work crew)

	฀	Facility-Based (i.e. participated in a sheltered workshop, work activity, etc.)

Work Related Issues (i.e. problems with reliability, other employees, employer, etc.):

Work-related successes, special skills, etc.:

Level of Satisfaction with Job (please circle): 1-Not Satisfied				2-Fairly Satisfied		3-Satisfied 4-Extremely Satisfied

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 4 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

9. Applicant’s Social Adjustment

• Does the Applicant have friends? Y N

•What type of person does the Applicant prefer as a friend (e.g. someone who is older, younger, or the same age, etc.)?

____________________________________________________________________________________________________

•	Does the Applicant take part in social activities? Y			N
•	Does the Applicant lead a lonely life? Y	N
•	Does the Applicant avoid other people?	Y	N
•	Does the Applicant pursue the opposite sex?		Y	N

•Additional Comments: _________________________________________________________________________________

_______________________________________________________________________________________________________

10.Applicant’s Problems (List any major health, psychological, physical, other related problems, and diagnoses that currently affect the Applicant’s life. If the applicant has a brain injury, please indicate whether the problem occurred before or after the brain injury.)

*Problem Area

*Problem Description

Who observed/

Documented the Problem?

(e.g. Mom, Dad, Doctor, Teacher,

Sister, Brother, etc.)

Date the

Problem

Was

Resolved

11. Brain Injury

If the applicant has a brain injury, please answer the following:

When (what date) did the brain injury occur? (Please try to be as precise as possible)

Describe the nature of the brain injury.

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 5 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

12. Applicant’s Use Of Prostheses/Specialized Equipment

Does the Applicant currently use a prosthesis or any specialized equipment? If so, list each item and whether it is used or not.

*Prosthesis/Specialized	Description		*Currently Uses?
Equipment	Description		*Currently Uses?
Equipment
		Currently Uses	Has, but doesn’t use

		Currently Uses	Has, but doesn’t use

		Currently Uses	Has, but doesn’t use

13.Applicant’s Medications (please list all of the medications the Applicant is currently taking)

*Medication Name	*Reason for Taking The	Prescribed By	Date Started	Date Stopped
	Medication		Taking the Med	Taking the Med

14.Applicant’s Utilization of Medication

•What is done to help/remind the Applicant to take their medication?______________________________________________

______________________________________________________________________________________________________

15.Substance Use

Does the Applicant currently use any substances (e.g. Alcohol, tobacco, etc.)? If so, enter the following:

Type of SubstanceFrequencyComments (Daily, Weekly, Monthly)

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 6 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

16.Applicant’s Health Treatments (List any recent visits the Applicant made to see a medical professional – including medical check-ups, outpatient treatments, dental exams, hospital stays, etc.)

*Type of Medical	Name of	Treated By	Name of	Type of Treatment	Treatment	Discharge/	Comments
Visit (e.g. Dental,	Medical	What Kind of	Facility		Start Date	Recovery
Neurological, Pediatrics,	Professional	Medical			or Date of	Date
Speech Therapy, Mental	Professional	Professional?			or Date of	Date
Speech Therapy, Mental		Professional?			Visit
Health)					Visit
Health)
				฀ Inpatient
				฀ Inpatient w/ Meds
				฀ Meds only
				฀ Outpatient
				฀ Outpatient w/ Meds
				฀ Inpatient
				฀ Inpatient w/ Meds
				฀ Meds only
				฀ Outpatient
				฀ Outpatient w/ Meds
				฀ Inpatient
				฀ Inpatient w/ Meds
				฀ Meds only
				฀ Outpatient
				฀ Outpatient w/ Meds
				฀ Inpatient
				฀ Inpatient w/ Meds
				฀ Meds only
				฀ Outpatient
				฀ Outpatient w/ Meds

17.Applicant’s Stay In A Nursing Facility (NF) / Intermediate Care Facility for the Mentally Retarded (ICFMR)

*Is the Applicant now, or have they ever been, a resident of a nursing home or an ICFMR? If so, please enter the following:

•Admission Date ____________

•Name of the facility ___________________________

•Discharge Date ____________

18.Applicant’s Allergies

Please list all of the Applicant’s Allergies

Type of Allergy	Comments

19. Applicant’s Immunizations

Fill in the Immunizations the Applicant has received.

Name of Immunization	Date Received	Who gave the Immunization?

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 7 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

20. Applicant’s Appetite

Is the Applicant’s current appetite: Good Fair Poor

21. Applicant’s Family Relationships

Father

*Name				Birth Date		Employed? Y	N
						Occupation:_________________________

Deceased? Y	N			Adopted the Applicant?		Telephone Number
Date: _________ Cause: _____________				Y	N

Ethnicity/Race				Provides Natural Supports?		Describe his relationship with the Applicant: (e.g.
				Y	N	good, positive, confrontational, etc.)

Does he speak English?		Y	N	Lives with the Applicant?
If not, what language? ________________				Y	N

Street Address (if not living with the Applicant):

Mother
*Name				Birth Date		Employed? Y	N
						Occupation:____________

Deceased? Y	N			Adopted the Applicant?		Telephone Number
Date: _________ Cause: _____________				Y	N

Ethnicity/Race				Provides Natural Supports?		Describe her relationship with the Applicant:
				Y	N	(e.g. good, positive, confrontational, etc.)

Does she speak English?		Y	N	Lives with the Applicant?
If not, what language? ________________				Y	N

Street Address (if not living with the Applicant):

Stepfather (if applicable)

*Name	Gender	Birth Date		Lives with		Provides	Adopted the		Describe his relationship with Applicant
			Applicant?			Natural	Applicant?		(e.g. good, positive, confrontational, etc.)
					Supports?
			Y	N	Y	N	Y	N

Street Address & Telephone # (if not living with the Applicant):

Stepmother (if applicable)
*Name	Gender	Birth Date		Lives with		Provides	Adopted the		Describe his relationship with Applicant
			Applicant?			Natural	Applicant?		(e.g. good, positive, confrontational, etc.)
					Supports?
			Y	N	Y	N	Y	N

Street Address & Telephone # (if not living with the Applicant):

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 8 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

Guardian (Does the Applicant have a court appointed Legal Guardian? If so, fill in the data below.)

*Name

Gender

Birth Date

Lives with

Provides

Describe relationship with Applicant

Applicant?

Natural

(e.g. good, positive, confrontational, etc.)

Supports?

*Street Address & Telephone # (if not living with the Applicant):

Spouse (if the Applicant is/was married)

*Name

Gender

Birth Date

Lives with

Marital Status

Provides

Describe relationship with Applicant

Applicant?

(i.e. Married,

Natural

(e.g. good, positive, confrontational, etc.)

Separated, or

Supports?

Divorced)

Street Address & Telephone # (if not living with the Applicant):

Siblings

*Name

Gender

Birth

Lives with

Provides

Address/Telephone (if not living with the

Describe relationship

Date

Applicant?

Natural

Applicant)

with Applicant

Supports?

(e.g. good, positive,

confrontational, etc.)

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 9 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

22.Applicant’s Other Personal Relationships [e.g. extended family, friends, etc.] (The people entered in this area are considered to be important to the applicant and contribute in some meaningful way to their daily living experiences)

Person’s	*What is the	Lives with			Provides	Address/Telephone (if not living with the	Describe relationship
Name	Relationship?	Applicant?			Natural	Applicant)	with Applicant
				Supports?			(e.g. good, positive,
							confrontational, etc.)
		Y	N	Y	N

		Y	N	Y	N

		Y	N	Y	N

		Y	N	Y	N

		Y	N	Y	N

		Y	N	Y	N

23. Applicant’s Professional Relationships (e.g. Doctor, Dentist, School Teacher, etc.)

Professional’s

Name

*Type of

Professional

Date

Professional

Was Last Seen

Professional’s

Telephone #

Professional’s Address

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 10 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

24. Family Tragedies

Has the Applicant’s immediate family encountered any tragedies (e.g. automobile accidents, deaths, major illnesses, etc.)? If so, list and describe them below:

What was the Incident?	Incident Date	Describe the Incident

25. Family Medical History

Does the Applicant have any family members who have notable medical issues or disabilities? If so, identify and describe the issues and/or disabilities.

Describe the Medical Issues/Disabilities

26. Agencies

Is the Applicant currently involved with any city, county, state or federal agencies? If so, enter the following:

*Name of the Agency AgencyDate the Agency Contact Person Case #Comments

Telephone Involvement

NumberStarted

Utah DHS DPSD	Division of Services for People with Disabilities (DSPD)	Page 11 of 11
12/2006	Applicant’s Name:_____________________________________________	Form 824L

27. Court Orders

Is the Applicant currently affected by any court orders that impact their relationship with DSPD? If so, enter the following:

What Kind of Order is it?	Date of the Order	Comments

28. Applicant’s Income

If the Applicant has an income, enter the following information:

Type of Income (e.g. earned,	Amount	With What Frequency is the		Is the
retirement, Social Security, etc.)		Income Received? (e.g. weekly,		Income
		monthly, annually, etc.)		Stable?
			Y	N

			Y	N

			Y	N

29. Assistance

Does the Applicant receive assistance from any private or government agencies? If so, enter the following information.

Type of Assistance (e.g. Food	Describe the Assistance	Amount	With What Frequency is the
Stamps, Housing, SIC, Unemployment,			Assistance Received? (e.g. weekly,
Charity, etc.)			monthly, one-time, etc.)
			monthly, one-time, etc.)

30. Insurance

If the Applicant receives insurance benefits either by himself/herself or through their family, enter the following:

Is the Insurance	Who Owns the	What Type of Insurance is it (e.g..	Insurance #	Insurance Start Date
Primary?	Insurance?	Private, Medicaid, Medicare, etc.)?

Form Completed By:_________________________________________	Date:____________
Intake Worker/Support Coordinator Signature:_____________________	Date:______________
QMRP/ABISC Signature (if applicable): __________________________	Date:______________

Question	Answer
Form Name	Form 824L
Form Length	11 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 45 sec
Other names	824L, social history assessment example, social history template, DHS

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