Child Well-Being Assessment Form

Basic Information

Child's Name Date of Birth Age Gender Male Female Other

Physical Health

General Health Status Excellent Good Fair Poor Health Concerns / Notes

Emotional & Social Well-Being

Emotional State Stable Sometimes Upset Frequently Upset Social Interaction Active Average Withdrawn Notes

Educational/Developmental Progress

School/Daycare Attendance Learning Progress On Track Slightly Behind Behind Notes

Family & Living Situation

Living Situation Family Relationships Supportive Stable Tense Unsafe Notes

Additional Comments

Comments