II. SOURCES OF INFORMATION AND WORKERS' CONTACTS (WITH DATES).
III. STATEMENT OF PROBLEM (ALL PROBLEMS REVEALED BY HOME, SCHOOL,
AGENCIES, AND CHILD).

IV. FAMILY HISTORY:

A. Paternal

Grandparents: Any evidence of particularly positive or negative history, health, or characteristics.

Father: Name; age; history; occupation; recreation; health; education; description; attitudes; personality.

Fraternity: Any evidence of particularly positive or negative history, health, or characteristics.

B. Maternal: Same for each as above. Add to history of mother her attitude to pregnancy, desire for children, etc.

C. Siblings: Name, age, occupation, or school grade. Any outstanding positive or negative characteristics. IQ, scholarship, attitudes, and relationships.

D. Substitute parents: Same as for father and mother.

V. PERSONAL HISTORY:

A. Health

2. Sleeping habits; night terrors; somnambulism.

3. Chorea.

4. Enuresis.

5. Epilepsy.

6. Temper tantrums.

7. Autoeroticism.

8. Fears and fixations.

9. Behavior traits.

10. Special abilities and disabilities.

11. Special likes and dislikes.

12. Ambitions and aspirations (social and economic).

C. Significant incidents in child's life.

D. Sex knowledge and experience.

E. Home responsibility.

F. Religious life and training.

G. School history.

H. Play life; recreation; hobbies; play preferred; playmates; clubs.

VI. ENVIRONMENT:
A. Home-

1. Description: Material home, regularity of life, evidences of pov

erty, cultural refinement, etc.

2. Relationship—

a. Husband and wife.

b. Parent-child.

c. Brothers-sisters.

3. Others in household and relationship to child.

4. Atmosphere, attitudes, discipline.

NOTE.-If former homes were different, make note of same.

B. Neighborhood.-Note whether rooming house, apartment, small home, down town, etc.

General atmosphere; room to play; any constructive or destructive influence.