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Candidate Data:
First Name: 
Last Name: 

Date of Birth:









Inter-Lakes Elementary School



Guardian Info:

First Name:


Last Name:



62 Pleasant Street Apt#4

Meredith, NH



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:

Student's mother has been out of the picture for over four years. Dad was in relationship with a female after mom and female 'kicked them out of her house on Christmas' a few years ago. Currently the student lives with his dad only.
Dad has been on and off disability and is currently trying to get back on disability for prior need. No income. The school helps with students food, shoes, boots, jacket, and other clothes. School also supports the student with his glasses.
Student is not connect with dad at all. Reports that dad has an 'addiction to video games.' Student reports that they don't spend any time together at all, they do not eat dinner together or engage in any time together.
Dad is completely unsupportive of remote learning to the point that when teachers have called to give certain log in codes when bot doesn't show dad says 'you will have to email Matthew.'

Organizations / Mentor Programs:

None. Used to be involved with boy scouts. Not interested in the community center after school though that has been offered. Meets with his school counselor once a week.

Special Assistance:

Student has a 504 plan for ADHD. He meets with the school counselor once a week.

Health Concerns:

Eye glasses.

Victim of Sexual Abuse:

Not that I am aware of.

Perpetrator of Sexual Abuse:

Not that I am aware of.

Victim of Physical Abuse:

Not that I am aware of.

Threatening or Aggressive Behavior:

Not per say. He has had some minor infractions of throwing snowballs at children during recess which again resulted (after second time) in calling home, a letter of apology, meet with AP and consequence.

Required Physical Restraint:


Personality / Social Standing:

I would say that Matthew is kind of in between. He is fairly social at recess and chats in class however he is really low/negative about most situations. His personality is dysthymic-esque.

He wants attention of adults in a loving/nurturing way. He does his work when he is at school but does NOTHING at home. He doesn't do any homework ever and never participates in remote learning.

His self esteem especially around adult relationships is vey low.

He 'plays' with peers and is active outside with them at recess but in class he really vibrates at a lower frequency as far as really low energy.

Behavioral Patterns:

Again, I would describe this student as very low energy emotionally. He comes in dirty, and often smelling like smoke. He has very real worries about his family 'having no money' or his 'dad dying of a heart attack' or 'helping to get his dad a job.' This weighs very heavy on Matthew. We talk about what is his worry versus what is his dad's worry. He states that dad has asthma and is 'trying to quit' smoking but often expresses worry about him.
Matthew seems to repeat things that he has heard from dad around his mom, and wanting nothing to do with her because she left them.
Matthew complains a lot about having nothing and says that his family 'needs money.' When asked about what items he might use the money for he states, 'more video games.'
Matthew's lack of engagement during remote time can be frustrating. Despite identifying student and parent roles in the 504 around remote learning, there was no follow through.
Matthew seems to lack motivation and not connect with any 'rewards' or 'consequences' with regards to his behavior and/or work completion. Despite setting small goals with short/varied rewards, Matthew continues to continue status quo which I believes reinforces his low self-esteem and 'I can't do it' attitude. This seems to mirror the way that dad acts.