CATHOLIC CHARITIES- DIOCESE OF METUCHEN

CONNECTIONS PROGRAM
SCHOOL INQUIRY
Date______________________
Child/Youth Name: _______________

Date of Birth: __________

Grade_______________

School Name and Address: __________________________________________________________

__________________________________________________________
__________________________________________________________
Name of person completing report: _________________________ Title: _____________________
Length of time child/youth known to you: ________Relationship with Student: ________________
Is this child in a special education program?____ If yes, what is their classification? ____________
A) GENERAL BEHAVIOR
(Please check all that apply)
___ Anti-social behavior
___ Non-delinquent, but resentful of controls and authority
___ Relatively normal and conforming
___ Tends to have few friends
___ Daydreams, withdraws
___ Other_________________(Please explain)_______________________________________
B. SPECIFIC PROBLEM AREAS
(Please check all that apply)
___ Parent-child relationship
___ Sibling relationship
___ School adjustment
___ Peer relationship
___ Parent interest in school
___ Economic deprivation
___ Physical symptoms: Nervous, Soiling, Allergies, etc.: Specify________________________
___ Other__________________(Please
explain)______________________________________

SCHOOL ADJUSTMENT
1.

How would you rate this childs intellectual potential?

a)

____ High

____ Above Avg.

____ Avg.

_____ Below Avg.

_____ Low

b) What is this based on? ____________________________________________________

2.

How would you rate this childs actual achievement in school?

a)

____ High
Low

b)

What is this based on?

_________________________________________________

3.

4.

____ Above Avg.

_____Avg.

_____Below Avg.

_____

List areas of academic

a)

Strengths:
___________________________________________________________

b)

Weaknesses:
_________________________________________________________
Briefly describe the childs attitude toward the controls and discipline of the classroom
and school setting.
_______________________________________________________________________

_______________________________________________________________________
5.

How has the childs academic record been generally?

______ Improved

_____ Remained the same

_____ Declined

Please explain: _____________________________________________________________

6.

Attendance record: _____ Poor _____ Fair

_____ Good

____ Excellent

7.

How well do you feel this child would relate to an adult volunteer? Please explain:
_______________________________________________________________________

_______________________________________________________________________
_______________________________________________________________________
8.

Would this child do well in one-to-one activities? Please explain:

_______________________________________________________________________

_______________________________________________________________________

9. Other comments:

_______________________________________________________________________

__________________________________________
Signature of Individual Completing Form
___________________________________
Date

Attached, please find the Release of Information Agreement completed by the client to
facilitate this inquiry. Thank you for your cooperation.

_________________________________________
Jeanette Nadonley / Rosi Pena