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Candidate Data:
First Name: 
Last Name: 

Date of Birth:









Broken Ground School



Guardian Info:

First Name:


Last Name:



12 East Side Dr., Apt. 401




Guardian/Family Phone:

Guardian/Family Email Address:

(603) 513-9799

Living Situation:

Mother w/ live-in boyfriend

Financial Situation:



Free/Reduced Lunch:




How many live in the household?


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


Household Situation:

Chase lives with his mother, his mother's boyfriend (of 3-4 years), his 14-year-old brother and his 2-year-old brother. Chase's older brother has contact with his biological father, but Chase has not had regular contact with his biological father for 2-3 years. Chase does not like it when people refer to his middle or last name because his father has these names as well. Chase also has an extremely antagonistic relationship with his mother's boyfriend. From what we can tell, he does not feel safe around him and has stated that the boyfriend has been rough with his younger brother and gave away Chase's pet cats (or let them go). Chase was consistently going to visit his paternal relatives (grandmother and aunt) most weekends last year, which he liked very much, but this was stopped. He recently spent vacation with his maternal grandparents and came back to school in a very happy mood, but this is rare. Chase adores his mother, but his mother is the sole breadwinner and works evenings, meaning her boyfriend is the primary caregiver most of the time.

Organizations / Mentor Programs:

He did a wrestling camp last year; no other programs.

Special Assistance:

Chase has an IEP because he is academically low. Earlier in the year, the guidance counselor was checking in with him regularly to give him some positive attention because he was making many negative statements about himself, and had a generally pessimistic outlook. His mood has improved as the year progressed and these occur less often now (both the statements and the visits with the counselor). He is generally well-behaved, although has many of the characteristics of ADHD (not diagnosed) and so will blurt out comments in the middle of a lesson or things like that.

Health Concerns:

We have talked with the family that he has many of the symptoms/behaviors of ADHD but they have not pursued a diagnosis

Victim of Sexual Abuse:


Perpetrator of Sexual Abuse:


Victim of Physical Abuse:

Chase has never said that he has been hurt, although has made comments about his mother's live-in boyfriend being rough with his younger brother. Based on his descriptions, DCYF has been called as part of mandated reporting, and followed-up once and did not another time. The case was closed without any recommendations being made.

Threatening or Aggressive Behavior:

Chase has threatened to hurt himself or kill himself several times. He has not had a realistic plan of how to do it, but he can be impulsive so these comments/threats are a concern. He tends to go through a time when he makes such comments often and then other times where he does not. Chase made statements of self-harm earlier in the year and then mimed/acted choking himself by wrapping the arms of his sweatshirt around his neck and tightening them. He has not made any such comments/gestures in several months. Chase has also voiced that should the mother's boyfriend threaten or "come after" him, Chase would hurt him and described a fairly realistic way that he might defend himself. He is not aggressive or threatening at school at all.

Required Physical Restraint:


Personality / Social Standing:

Chase was new to the school last year (Broken Ground is 3rd - 5th) and he was in-person 2 days/week at the beginning of the year because of COVID scheduling. He was very suspicious of people, unwilling to be helped, and would often not do work (he is very low academically). Chase can have a very negative outlook, which stems from his own low self-esteem and will insult himself frequently. When he is in this mindset, he can be rude/off-putting/irritable with others. He is never mean. This year, Chase has really opened up in terms of trusting staff and peers and has completed much more academic work, which has led to a lot of good progress, which, in turn, has seemed to help with his self-esteem. He is socially much more of a follower than a leader (because he doesn't believe in himself), but he will notice if someone is being left out and be sure to include them. He has a few close friends and gets along well with his classmates in general. He is generally good with authority; he almost always listens to teachers/staff, but really *works* with the adults that he has a good relationship with.

Behavioral Patterns:

Chase is generally really good behaviorally and has not gotten in trouble often this year. Last year was harder when he would refuse to do work, and he was rude/disrespectful during those times. This year, the most consistent notable behavior pattern is that he will become very defensive and stick up for peers when they get in trouble with adults. He does not become rude, but he does have to be reminded to let the student take care of their own business.


Chase has such fragile sense of his worth and is only just now starting to believe in himself a little, but this is a significant uphill battle for him. He will always struggle academically and so school is not necessarily an area of success for him (despite the strides he has made), he is not involved in other activities that allow him to shine, and he does not have a supportive home that he can rely on. He can sink into a negative mindset of he sees no point in trying because it doesn't get him anywhere- school is still hard, his mother's boyfriend still lives with them, etc. However, once you can break through the suspiciousness, Chase is a loving and kind young boy with so much potential. He has never had a positive male role model and I worry that he will develop a skewed idea of what it means to be a strong male figure. He has started to work hard at school because he sees that his efforts have paid off, but he needs to recognize his own power throughout his life- beyond school. I think that being able to experience who he is away from the stressors of his family life and the difficulties he faces at school would be a once-in-a-lifetime opportunity for him that he will not have the chance to get anywhere else. I think that he would also benefit tremendously from being surrounded by other boys his age who have similar circumstances as he does. He very much needs to learn to believe in himself and would benefit enormously from an ongoing mentor, as a role model but also as someone (outside of school) maintaining that longer, reliable relationship. Chase would absolutely be the kind of camper that would be a role model to other campers in many ways, but also so badly needs the type of self-empowerment that the program fosters.