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Candidate Data:
First Name: 
Last Name: 

Date of Birth:









Beaver Meadow School



Guardian Info:

First Name:


Last Name:



29 Bog Road




Guardian/Family Phone:

Guardian/Family Email Address:

Living Situation:

Single Father

Financial Situation:


Free/Reduced Lunch:



How many live in the household?


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


Household Situation:

Riley's mother left the family when Riley was 2 or 3 years old and moved to Pennsylvania. They have not seen her since. Riley reports that his dad and brother watch a lot of TV and play video games. Dad sleeps a lot after work and there doesn't appear to be much interaction on school nights. Dad relies heavily on the grandparents for support. Riley has a good relationship with them.

Organizations / Mentor Programs:

Riley attends the YMCA@21C after school program here at BMS. Riley also joined the school band this year and plays the trombone. Each summer he attends the Spaulding summer day camp.

Special Assistance:

Riley has weekly guidance check-ins and lunch bunches. Riley requires many modifications throughout the day to complete his work but has no IEP or 504 at this time. He was referred to Special Education this year but refused to complete the testing portion of the assessments for us to move forward with the referral. Data is collected each day for Riley's behavior, allowing us to find targeted times that he has difficulty and proactive breaks are supported by our school-wide behavior specialist.

Health Concerns:

Sleep pattern is inconsistent. He gets up at 4:30 to get ready for school before dad has to go to work. He has attentional difficulties and impulsivity. Riley also has a poor diet.

Victim of Sexual Abuse:

Not that we are aware of.

Perpetrator of Sexual Abuse:

Not that we are aware of.

Victim of Physical Abuse:

Not that we are aware of.

Threatening or Aggressive Behavior:

Yes-throws shoes at staff and has hands-on. Throws objects and shoves at peers as well. Threatens others when in crisis. We saw this more at the beginning of the year and around school breaks when routine is not regular.

Required Physical Restraint:

No- we wait him out unless he acted on the threats of self-harm and/or safety of others. We do need to evacuate the classroom when he is in crisis. Crisis presents as yelling, banging, and making it difficult for anyone in the class to learn in the environment he creates.

Personality / Social Standing:

Riley prefers to do what he wants, when he wants. He does not see the effects of his distractions on his peers. He gets very upset when they have similar behaviors. He cannot self-regulate or chooses not to. Peers have reached a point of no longer being empathetic. In a non-academic event, such as lunch bunch, he chooses peers and acts appropriately. Academically, he only works with adults on preferred activities. He has very low self-esteem. He frequently feels/verbalizes that peers and teachers think he is stupid. Riley is neither a leader or a follower.

Behavioral Patterns:

The behavior occurs when anything is not a preferred activity or the people involved are not preferred. He will also sabotage for other students if he doesn't want something to happen in the classroom (ie. read aloud, writing time, science activity). He never takes ownership of his actions and blames others for his behavior. He often does not apologize and rarely can flexibly think to adjust his expectations. He becomes particularly frustrated and disruptive during reading and writing. He succeeds in math and science if the activity is preferred. Riley is a hands-on learner and enjoys activities like coding and working with Legos and robotics. When Riley is at baseline he can often be helpful and engaging in conversation. He enjoys working with younger students.


Riley misses his mother terribly. He talks about her daily and struggles with her loss. Riley would benefit from additional interpersonal relationships with adults and students his own age. His concept of family and love has been impacted by the amount of loss he has experienced; essentially he has lost all "hope". His negative outlook impacts his ability to form and maintain meaningful, healthy relationships. With that said, he enters each and every day with a glass-half-empty outlook. He needs this opportunity and/or people to help him explore his unknown. Riley would benefit greatly from this opportunity, if given. Please feel free to reach out to me with any questions or concerns.