Parent Questionnaire

Youth Initiative High School
Boarding Student Application for Admission

* Indicates required field

Student Name *

First

Last

Parent/Guardian Name *

First

Last

Please describe any serious illnesses or issues your child has had. *

Describe your child's academic life. What do you consider to be strong points and weak points? *

Please describe his/her relationships with classmates and teachers. *

Has your child ever undergone psychiatric therapy or psychological counseling? Please describe. *

Does your child have any learning, behavioral, or emotional difficulties? Please describe. *

Has your child had educational testing? If yes, please include a copy of the report. *

Has your child used alcohol, nicotine, marijuana, or other drugs? Please explain. *

Please share any other information that may help the Youth Initiative and your host family to understand and serve your student. *