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Candidate Data:
First Name: 
Last Name: 

Date of Birth:









Woodland Heights Elementary School



Guardian Info:

First Name:


Last Name:



27 Woodland Ave




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:

Charlie lives with mom and his high school aged sister. Charlie will also sometimes spend time at his dads, but is primarily with mom. Charlie has a good relationship with mom, but has witnessed some domestic violence prior to his parents divorce. I believe him and his sister were also sometimes caught in the middle during fights. His former school reported that mom has a depressive personality and struggles with some mental health issues. Charlie also struggles with some mental health issues and depressive tendencies. He appears to have a good relationship with both mom and dad. He wishes he could spend more time with dad, but I believe dad has an off work schedule.

Organizations / Mentor Programs:


Special Assistance:

Charlie visits guidance often. He says he is anxious and depressed, although I don't think he is diagnosed. He has also been put in groups before to work on some self regulation skills when he gets into his stuck, depressive episodes.

Health Concerns:

No immediate health concerns.

Victim of Sexual Abuse:

Not that I know of

Perpetrator of Sexual Abuse:


Victim of Physical Abuse:


Threatening or Aggressive Behavior:

Charlie has said he wants to kill himself, however he usually doesn't mean it and just gets stuck in that mind space. He will often say negative remarks to get some attention from either peers or adults.

Required Physical Restraint:


Personality / Social Standing:

Charlie is somehow both introverted and extroverted. He can be a social butterfly when he's having a good day. He likes to talk to other kids and joke around. But on the days where something has gotten him stuck or he's had a rough start, he will stay in that negative space claiming "no one likes him" and "he has no friends". I believe he likes to be a leader, but will often easily follow the crowd. Charlie is great with adults. He follows direction nicely, the only time he's hard to communicate with is when he's so stuck, but even then if you talk and give him some time he will follow any direction. He is great with his peers, although can be awkward and make self loathing comments loudly for the whole group to hear. He has very low self esteem. He doesn't think he is smart or nice or a good friend. He has a very negative view about everything about him. No matter how much you tell him how smart or nice he is, he just will believe what he wants to believe.

Behavioral Patterns:

Charlie is so negative to himself. Even on great days, there's always a comment about hating something about himself or being negative. It's so frustrating because you can let him talk it out and give him some tips and tell him how great he is, but he will stay stuck on that negative thought until you kind of just give him some time, then have him return to class or what he was to be doing.


Charlie is a wonderful boy. He has some clear mental health issues that have yet to be addressed, but he tries really hard to get through them. He is smart, funny, and creative. He loves cooking, he hopes to become a chef in the future. I truly think he would be so successful in this program. He needs some support and positive influences to help him with his self esteem. I think its important he has a mentor and someone to connect with for as long as possible. He needs some positive influence in his life and I think this would be the perfect program. I also think he would have so much fun and benefit from having somewhere to be during the summer.