Camp Alumni Survey

Please take a few minutes and fill out this survey. By filling out this survey, I can make sure I’m clear on your goals and overall needs in this program. This information is confidential and will NOT be shared.

Parent Name(s):




Oldest Child - Name: Age:

Next Oldest Child - Name: Age:

Next Child - Name: Age:

Child's - Name: Age:

Child - Name: Age:

Camp(s) attended and Year:

Most Challenging Child’s Name:


State/Country of origin:

Came to this family at age:

Previous Trauma: PhysicalSexualEmotionalPrenatal AlcoholPrenatal DrugsMeth Exposure

Number of moves child has had:

Visits with perpetrator of trauma: NoneIn the PastCurrently

Current Therapist:

Current Medication:

Current Child Concerns:

DietSleepDigestionConstipationAllergiesSensoryDevelopmentAilments (list)

IQ: LowAverageHighVery High

Home behavior concerns (list):

School behavior concerns (list):

Public behavior concerns (list):

Other info you want me to know (list):

Thank you for taking the time to fill this out. I know your time is valuable! This info will help me expedite the course to be the most beneficial to you. I want to be sure I leave no stone unturned in helping you with your quest for success with the children. I know your investment of time and energy during this course will pay big dividends! I believe this program could be a turning point for your family to have lots more love and laughter!

We can make a difference,