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Candidate Data:
First Name: 
Last Name: 

Date of Birth:









Bristol Elementary School



Guardian Info:

First Name:


Last Name:



459 Lake St #C




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:

Mason currently lives with his mother and two sisters. He seems to have a good relationship with all three women. Mom works from home sometimes but is the only one to earn income for the household. Mason visits his father on some weekends. At his dad's house, there is a girlfriend and her son who is about Mason's age. Mason talks about his weekends with dad and the girlfriend's son. It seems as though they do not get along very well. When he is there Mason says he plays video games a lot. He misses his dad a lot when he is not with him which can interfere with his days at school. Mason can get down on himself and have irrational thoughts about his dad (i.e. "I'll never see him again.")

Organizations / Mentor Programs:

TTCC afterschool program

Special Assistance:

Mason is on a 504 plan. He receives Title 1 services in both reading and math. He visits the School Counselor 1 x/week for 20 - 30 minutes.

Health Concerns:


Victim of Sexual Abuse:


Perpetrator of Sexual Abuse:


Victim of Physical Abuse:


Threatening or Aggressive Behavior:

Last year Mason had some suicide ideations. He made comments (at school) about hurting himself and even demonstrated how he may carry out his thoughts. He went to the ER and was evaluated. After that episode, he began counseling outside of school. On the playground, Mason can play aggressively with his peers.

Required Physical Restraint:


Personality / Social Standing:

Mason is a friendly child who really enjoys pleasing others. He does have low self esteem and can say negative things about himself. Mason has a history of poor peer interactions. He tends to get into peer "triangles" where he feels others are taking his friends away from him. Mason is introverted and is a follower, not a leader. He does well with authority. He is not disrespectful to his teachers and wants to please.

Behavioral Patterns:

Mason will have stretches of time where he does well with peers. His emotional state will be good and he will function well in/out of class. Some times, Mason will get down on himself, struggle with peer relationships, and become very sad about his father. When he gets like this Mason will cry. He will exaggerate issues regarding his peers or father and will need time to calm himself.


Mason is a great kid. He is fun, willing to please, and excited and open to trying new things. I believe that Mason would thrive in the Mayhew environment. He would love the camaraderie with the boys and would really do well having the mentor throughout the year. Although Mason visits his father, I know that he would truly benefit from other positive male role models. Mason has a great personality. He wants to earn his friends respects but needs help in doing so. He is respectful. He follows directions and does not tend to argue with adults. I believe that Mason is the type of Mayhew candidate that would give back to the program as an adult. He needs a little guidance, especially as he gets older. I feel that he would succeed as a Mayhew participant.