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Candidate Data:
First Name: 
Last Name: 

Date of Birth:









Pleasant Street School



Guardian Info:

First Name:


Last Name:



104 Academy Street #2




Guardian/Family Phone:

Guardian/Family Email Address:


Living Situation:

Single Mother

Financial Situation:



Free/Reduced Lunch:




How many live in the household?


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


Household Situation:

Michael lives with his mother, Marissa and brother, Eli. Marissa states that she is very protective of him with meeting friends in his neighborhood and she wishes there was a place where he could build friendships with others outside of a school setting. Michael and Eli get along well, but they have their brotherly moments. Eli is 17 and sometimes is immature whereas Michael is more mature for his age. Michael worries about Eli when he's not home. They love each other but they argue. His biological father passed away in a car accident and Michael had a connection with him for the first couple years of his life. Eli's dad passed away as well. Michael and Marissa are very close, but she says its like pulling teeth trying to get him to talk about his feelings and his day. Marissa talked about how she was neglecting the boys due to her own issues and felt that someone needed to care for them before DCYF got involved, so they went with her ex boyfriends grandmother who she had a good relationship with. Her name is Nancy, and she's a great support for him. He went with Nancy when mom was struggling for a year and half but had some contact with mom throughout that time.

Organizations / Mentor Programs:

Michael isn't yet but Marissa has been thinking about it.

Special Assistance:

Michael had an IEP since 2nd grade and was recently discharged. He doesn't have regular guidance visits or go to the resource room.

Health Concerns:

Michael does not have any health concerns.

Victim of Sexual Abuse:


Perpetrator of Sexual Abuse:


Victim of Physical Abuse:


Threatening or Aggressive Behavior:


Required Physical Restraint:


Personality / Social Standing:

Michael is a very caring and considerate boy. He has a huge heart. He is always worried about his mother's feelings. He is such a love. He listens really well to Marissa. He's always been a really good kid. He internalizes things. He loves art and Marissa has been trying to help him to develop this hobby. Michael is more of a follower than a leader but has good friendships in school. He tries to gain peer attention by being funny and floats between peer groups depending on what social situation he is in and seems a little uncomfortable because he doesn't know quite where he fits in. He responds well to authority. More recently he's been changing the way he wants to dress and he styles his hair. Michael appears a little reserved at times.

Behavioral Patterns:

Michael has lived in two different homes. Nancy is generationally older and Marissa is more young and relaxed with her parenting which has been a little bit of a struggle for him to have different expectations. Marissa says she lets him get away with some things like not doing chores, but she is working on that. They are still finding their way as mother and son and navigating life. He is so caring about other kids and adults, and has never gotten into a fight. He is not a violent child.


Michael has a background of trauma including his father who passed away and being separated from his mother. His brother, Eli, struggles and a lot of Marissa's time is spent trying to support him and Michael sometimes doesn't get much attention, and she feels bad about that. Marissa tries to instill that they are a family even though they've been separated at times. Michael would thrive with the opportunity to become part of the Mayhew Program. He is in need of a positive male role model, and Marissa hopes that this will give him a chance to make new friends and create lasting relationships. Michael will have the experience of being on an island at a sleep away camp which he wouldn't get without this. Marissa went to a camp as a child and had the time of her life. She knows that she probably wont be able to give him opportunities like canoeing and other outdoor activities and she really wants him to experience those activities that she can't give him. This will give Michael the chance to connect with male counselors and to have a positive role model to show Michael that there is another path to life even though he looks up to his brother so much. Please consider accepting Michael into your program. This can be life changing for this boy who could very easily slip between the cracks and not have opportunities to succeed.