Professional Questionnaire


Camp Akeela Camper Application



PART IV - Professional Questionnaire

All fields required.

You have been asked to complete this form because of your professional relationship with a child who has applied to our summer camp program. (We have already obtained parental consent for our communication.) If you would prefer to speak with us by phone, in lieu of completing this form, please let us know by phone (866-680-4744) or email (debbie-at-campakeela.com).

Camp Akeela is an overnight camp community in Vermont for children who need support in their social skill development. Our mission is to provide our campers with a summer filled with fun, friendship and personal success. If you have any questions or concerns, we would love to speak to you. Please do not hesitate to call or email us.

Child's Name:                   
Your Name:                      
Your Email:                     
Your Relationship to the Child: 
Length of Relationship:         

Child's Strengths:

How does this child interact with peers? (Give examples if possible.) If you've never seen this child with his/her peers, how does he/she describe these interactions to you?

Does he/she enjoy the company of others?

What strategies/interventions have you found work best with this child?

To your knowledge, has this child ever been aggressive, self-injurious, threatened or idealized about suicide?

What is the most important thing we should know about this child given the nature of our camp community (namely, a place for very high-functioning, bright and independent children who need some support in their social skills development)?

Do you feel that this child will most likely be successful at Camp Akeela? How would you define success for this camper?

Your Electronic Signature:

(Please type your name.)

Please type the code shown in the image.

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When you're finished, please click this submit button once only. Thank you!