Youth Program Teacher/Counselor Questionnaire 2024

You have been selected by a family to provide information to support their youth program or summer camp application. Thank you! 

If you have overall questions, contact afterschool@pbha.org or sup@pbha.org, respectively. You may read individual program descriptions, eligibility requirements and target population, and email each program's directors for any specific questions - available at http://pbha.org/programs/.

About the Application Process:
  • This questionnaire came from an application/interest form for a student of yours who listed your name. They have already completed most other steps to apply!
  • You may complete this form more than once for separate students.
  • Program directors will not follow up with Teachers/Counselors individually unless extenuating circumstances arise with the child/family.
Information needed to complete this questionnaire:
  • Knowledge of student's strengths and needs in academic performance, language skills, social-emotional, behavioral, and differentiated areas.
Child information
Filling out the following information for this applicant to a PBHA Youth Program:








School information


Grade in school entering in Fall
Your Contact Information





Student Referral Details

This information given may be used by a child's youth program director counselor or volunteer to get to know how to build relationship and build skills with the student and family during orientation, goal-setting, grouping, and social and academic learning. Leave blank any areas in which you have no information. No particular answers to these questions will help or hinder the child's referral to a program.
Academic Performance: Please indicate this student's performance in relation to grade level standards in the following subject areas:
Poor = Significantly below...; Needs Improvement = Somewhat below...; Satisfactory = at... ; Very Good = above...  grade level standards

Reading
Verbal Communication
Written Communication
Mathematical Reasoning

Social-Emotional Support: Please indicate how often this student:

Communication

Relations with Peers

Relations with Adults


Thank you for taking time to support this young person!


If you would like to refer other families to the Summer Urban Programs specifically, please fill out this referral form (also available on PBHA's website).


(Once you confirm, it may take a few seconds to submit).