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Candidate Data:
First Name: 
Last Name: 

Date of Birth:












Guardian Info:

First Name:


Last Name:



20 Thatcher Hill Road




Guardian/Family Phone:

Guardian/Family Email Address:


Living Situation:


Mother and step-father have separated, history of domestic violence. Mother is sole custodian, though child does spend time with both mother and her ex partner separately.

Financial Situation:



Free/Reduced Lunch:






How many live in the household?


How many work and/or provide income to support the household?


Household Situation:

There is a history of domestic violence between Mason's mother and step-father (which Mason has witnessed) which has resulted in their separation. Mason has been spending time with both his mother and step-father. The atmosphere seems like it is unstable and unpredictable with the relationship between adults. Mason feels very connected to and supported by his mother but it seems like he has not been spending much time with her with the separation. Mother continues to be sole custodian of Mason. This is the reason "other" was selected for family situation, the situation continues to evolve and change. Mason has a younger half brother, who is biological son of his step-father.

Organizations / Mentor Programs:

Mason is a cheerleader for Northern Lights.

Special Assistance:

No, Mason meets with the counselor on an as needed basis, typical of other students in the school.

Health Concerns:


Victim of Sexual Abuse:


Perpetrator of Sexual Abuse:


Victim of Physical Abuse:

No, though he has been witness to domestic violence between his mother and stepfather.

Threatening or Aggressive Behavior:

Mason does not have a history of threatening/aggressive behavior towards himself or others. When he gets frustrated, he can cry and shut down.

Required Physical Restraint:


Personality / Social Standing:

Mason is overall a wonderful student to have at school. Being the new school counselor this year, we have formed a strong relationship in our short time together. He presents as extroverted and his personality shines when he is with peers whom he connects with. Mason tends to associate with peers where he can take on a leadership role where peers are more passive. Mason generally enjoys school and has positive relationships with peers. From what I have witnessed, Mason responds respectfully to authority. When he becomes comfortable with individuals, he is much more likely to open up and show his great personality. Mason's self-esteem can vacillate depending on what activity he is engaged in.

Behavioral Patterns:

At times, Mason's behavior can be driven by hunger. He shuts down and can get very frustrated when he is hungry. Mason can also become frustrated when a given academic task is perceived as difficult to him. Mason is typically able to process what is bothering him and return to class or the activity once he is regulated.

Mason's behavior shifts and he is more quick to frustration when there are issues going on in the home.


Mason has had an inconsistent home life and has been exposed to domestic violence and changes in relationship dynamics within his home. Mason has a very strong relationship with his mother who is his sole custodian. When Mason is in a positive emotional space, he engages well with peers, does well academically and thrives in school. Given his family history, Mason does have a tendency to become easily frustrated and overwhelmed when factors outside of his control are impacting him. Though this is my first year working with Mason, it seems that his overall frustrations have decreased and he has been more engaged and connected in school this year. This has to do with both Mason's ability to grow and his connections he has created within the school.

Mason is a child who thrives on positive relationships and building connections and I believe Camp Mayhew would give him the space to build these very positive connections. I also believe that Camp Mayhew would offer strong and positive male role models that have been lacking for Mason given his living situation. Camp Mayhew would also offer consistency and a safe space for a child who has lacked this for much of his life. With positive role models and stability, Mason thrives. I truly believe his mother is trying to support his needs the best she can but has experienced many difficulties. This opportunity would be incredible for Mason and I think would greatly help to build his confidence, continue to build skills to manage his emotions and frustrations, and build positive relationships that will continue to lead him in a positive direction.