Professional References

Questionnaire for Professionals

Dear Professional,

You have been asked to complete this form because of your professional relationship with a child who has applied to Camp Sequoia. Please return this questionnaire to our office via email, fax or postal mail. You do not need to return this form to the student’s parents and the information you provide will be kept confidential. Our contact information is listed below. Thank you very much for your help in providing us with this information.

Camp Sequoia is an overnight summer camp for boys who present with social skill needs. Our campers present with average to above average cognitive ability and full use of language. Our program is an active, highly structured camp program with a focus on building social thinking skills. Camp Sequoia does not serve campers who need an extensive behavioral support program, present with aggressive/oppositional behaviors or have limited language skills.

If you have any questions or concerns, please do not hesitate to call or email us.

Student's Name*

First

Last

Current Grade

Age

Your Name

First

Last

Your Email

Work Phone

How long have you been working with this student?

In what capacity?

Please list this student’s diagnostic labels (example: ADHD, NVLD, etc.):

How would this student’s peers describe him regarding his social interaction?

Does this student have age-appropriate communication skills (relative to his age)?

Yes
No

Where does this student fall in regards to his cognitive ability relative to his same-age peer?

In regard to the student’s acceptance of authority, would you describe him as most frequently being:

Willingly cooperative
Sometimes uncooperative
Often resistant to authority

How is this demonstrated if he presents as sometimes uncooperative or resistant to authority:

Please comment on how this student takes guidance/directions from same-age peers:

Describe how this student expresses emotion (age appropriately, over-reactive, etc.):

On a scale from 1-10 (1 being the least and 10 being the most) what would you rate this student in terms of the level of negativity he expresses (i.e. complains, rigid thinking, unwilling to try new things):

Please enter a number from 1 to 10.

How would you describe this student’s ability to be part of a (social or academic) peer group?

Can successfully be part of a peer group
Has some difficulty working in peer groups
Needs support in order to advocate for himself
Has significant difficulty working in a peer group

Does he react with emotional outburst or aggression to provocation or frustration?

Yes
No
In the past but not recently

Please explain:

Please comment on the student’s ability to accurately interpret social situations:

Does this student require the support of an aide in school?

Yes
No

Full Scale IQ

Verbal IQ

Date of testing

Additional comments

Consent*

I agree to the privacy policy.

By checking this box, I confirm I'm authorized to submit this information regarding this child.

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