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Perry County Community Task Force CHAMPS Mentoring Program
CHECKLIST OF NEEDS
Child’s name:_________________________________ Grade:_______________ School:_______________________________________ Parents’/Guardians’ name:____________________________________________ Address:_____________________________________Phone #:______________
Academic problems: ___________Specific subject matter ___________Study skills ___________Organizational skills ___________Doesn’t turn in work
Social concerns: ___________Difficulty getting along with others ___________Wants to be alone most of the time ___________Low self-esteem
Behavioral problems: ___________Lack of self control, such as inappropriate talking or behavior ___________Aggression
Repeated absences: ___________Frequently ill ___________Unexcused absences
Out of school characteristics: ___________In personal crisis situation ___________Other stresses, such as family difficulties, peer pressures, chemical dependency concerns, etc.
Additional information on child’s needs:________________________________ ______________________________________________________________ ______________________________________________________________
Person filling out checklist:_________________________________ Relationship to child:_____________________________________
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