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Candidate Data:
First Name: 
Last Name: 

Date of Birth:









Berlin Middle School



Guardian Info:

First Name:


Last Name:



43 Cambridge St




Guardian/Family Phone:

Guardian/Family Email Address:

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:

Bio mom and bio dad were married. Both were substance users and the youth was put into foster care for a while and then lived with grandparents until mom got sober. Bio dad is in a new relationship and both of them still use. Youth was visiting Bio dad but due to the excessive drug use, mental and physical abuse, Bio dad lost visitation and was court ordered to follow specific requirements in order to have contact with the youth. Bio dad has not complied. Supervised visitation was ordered but Bio dad has not agreed on supervisor and has had minimal contact with the youth since September 2021. When the youth was visiting his Bio dad, he witnessed drug use, domestic violence and was punished more than the step mothers children. The step mother tries everything she can to cause turmoil between Bio dad and the youth.
The youth now lives with Bio mom full time and she has just placed a stalking order against Bio dad, preventing him from talking or seeing the youth until he complies with the court ordered agreement due to gaslighting and parental alienation during phone conversations with the youth.
The youth is struggling with the newly blended family. He has 2 step sisters who are 7 and 8 and a new baby sister. He often will argue with his siblings and this causes a lot of friction in the home. The Bio mom and her boyfriend have very different parenting styles and this is confusing to the youth.
The youth has limited contact with the paternal grandparents due to a history of parental alienation against Bio-mom and no contact with maternal grandparents.

Organizations / Mentor Programs:

None due to financial restraints

Special Assistance:

The youth receives a 504 so he can wear headphones, leave class so he can speak with a counselor at any time ( this is due to spontaneous bouts of depression and anxiety which cause him to cry), he has a specific bathroom he can use if he needs to go cry. He is allowed to fidget and chew gum, due to a history of biting holes in his lips and cheek, he is allowed to wear a hat due to his Trichotillomania
The school often calls him out when he is utilizing these things due to lack of communication and this often stress the youth out more.

Health Concerns:

The youth's severe anxiety causes him to pull huge chunks of his hair out and causes him to become physically ill

Victim of Sexual Abuse:

No abuse that I am aware of or that Bio mom reports but the youth was exposed to sexual advances by his step brother who is 2 years older while visiting his Bio dad. His Bio dad and the step mother didn't believe him and nothing was done about it

Perpetrator of Sexual Abuse:


Victim of Physical Abuse:

The youth reports that while visiting his Bio dad, the step mother got upset with him and tried to stab him in his eye with a pencil. He reports "getting beat" if he didn't do something the way he was supposed to or fast enough.

Threatening or Aggressive Behavior:

The youth will sometimes bang his head against the wall out of frustration but has not been injured or caused physical damage due to this behavior.

Required Physical Restraint:

No, not that has been reported

Personality / Social Standing:

The youth will respectfully question authority, just to get an understanding of what is being asked of him, as encouraged by Bio mom and how there family culture is in the home. He has a couple good friends in school that he sees outside of school. The youth reports hating school and not having any adults he responds to.
He is inquisitive but not defiant.
He is easy to talk with and is very open about things that bother him.
His self-esteem is very poor, he doubts himself, looks for admiration and acceptance from others, he has poor sleep habits due to the constant worry and self doubt.
He is kind to his sisters when they are getting along and loves his baby sister.
He is kind and gentle.

Behavioral Patterns:

The youth will talk about how good he is at something, specifically Basketball, but doesn't practice and therefore is not very good which causes him to feel like a failure and perpetuates the anxiety and low self-esteem.
He cycles between feeling really good about himself and then feeling like a failure.
He can sit in his head and will get lost in bad feelings which makes him spiral into the feelings of low self worth.


The youth is determined to feel better and to succeed in school and in activities. He wants to be a doctor and cure cancer so no one will die or get sick. He has a huge heart and feels things deeply. He has an engineering type mind and can build block towers that are not only imaginative but structurally sound.
He is willing to discuss what upsets him when presented the opportunity and is respectful especially when respect is given.
The youth will excel in an atmosphere that is supportive, understanding, creative, and provides him with physical activities to utilize his energy in a constructive way.
The youth has been exposed to domestic violence and substance abuse his entire life. He has removed from Bio-parents, placed in foster care and then lived with his paternal grandmother and exposed to gaslighting and parental alienation from his Bio mom.
Currently his home life is stressful, with Bio mom in a new relationship, 2 new step siblings and a new baby. He desperately wants and desires a relationship with his father and now mom is back in court with the stalking order. He has had to grow up very fast and has been exposed to many hardships for his age. I feel the youth could use a break from his home, his family tensions, court and the stressed from life for awhile to see that life doesn't have to always be this hard.
The youth is an excellent candidate for your program and I think he will succeed and benefit from everything that is offered. He is a bright and sweet boy that just needs to recognize his worth and importance in the world.
The youth is not from a single home currently, but this was very recent and has caused a lot of upheaval. He is located out of your catchment area but I think based on this referral should be considered despite not being the typical candidate. Please contact me for any further information if needed.