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Candidate Data:
First Name: 
Last Name: 

Date of Birth:









Wheelock ElementarySchool



Guardian Info:

First Name:


Last Name:



82 South Lincoln Street




Guardian/Family Phone:

Guardian/Family Email Address:

Living Situation:


mother with step dad

Financial Situation:



Free/Reduced Lunch:






How many live in the household?


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


Household Situation:

Dominic's relationship with Mom is typical mom and Son relationship but he can hold grudges and tries to manipulate Mom.
Dominic's relationship with his step-Dad is good because he is patient and go with the flow.
Dominic's relationship with his Sister is typical
Dominic's relationship with his step brother is good because they are closer in age.
Dominic can be possessive of items that belong to him. Especially items from his deceased Dad.

Organizations / Mentor Programs:


Special Assistance:

No. He recently joined our School and was home schooled for the last several years.

Health Concerns:

No concerns at this time.
He has asthma
He has hypermobility and sees orthopedics to monitor it.

Victim of Sexual Abuse:

No. Mom shared not that she is aware of.

Perpetrator of Sexual Abuse:

No. Mom shared not that she is aware of

Victim of Physical Abuse:

Yes. His biological father was on drugs and hit him with a belt. This happened when he was 4 or 5. There was a no-contact order for 2 years.
It happened when she was at work. DCYF was involved. His Father died when he was 7
Dominic witnessed physical abuse against his Mom from his Dad. He lived with his Grandparents, per Mom request, so she could file with the Police.

Threatening or Aggressive Behavior:

In Connecticut, at age 6, he was hospitalized for self- harm and aggressive behavior towards others. He also had panic attacks. When he got to the ER he tried to bit a Nurse. 10 days each time. This was a time when his Dad was trying to reach out to him because the contact order had lifted.

Required Physical Restraint:

After being released from his first stay someone came to the house to help Mom learn how to handle him.

Personality / Social Standing:

He enjoys the indoors and outdoors. He mostly plays with his Younger Sisters friends. There isn't kids his age in their neighborhood. He struggles to understand when kids are bring serious or joking. Peer connections are hard for him because he is on the spectrum .
He doesn't prefer to be alone or with others.
He likes to play video games with others and play outside (basketball).
Dominic has low self-esteem. He talks negatively about himself. He shares that he doesn't feel good about himself.

Behavioral Patterns:

Dominic's behavioral patterns include manipulation to get what he wants. He will sometimes be physical with his Sister and attempts to be physical with Mom but isn't successful. She let's him know she will bring him to the hospital or the police station .


Dominic is a good candidate for this program because of all the trauma he has been through and he is at risk for getting in trouble and school and in the community. Mom has concerns because of his genetics and how aggressive his Dad was ,his Dad went to jail, and the fact that he overdosed on drugs and died.

Dominic is new to our School. He was Home Schooled from 3rd Grade - until about a month ago. I spoke with his Mom and we filled this out together. She shared that she started home schooling him in 3rd Grade because he was bullied at his old school.