Behavioral Intake & Profile

Our goal at Camp Arnes is for every camper to establish good relationships with staff and other campers and to have a successful Camp experience. Part of this is recognizing that some children attending Camp may struggle with behavioral challenges and that no two children are exactly alike. We ask that the parents of any child who requires medication for such challenges, or who has struggled at Camp in previous years, complete a behavioral profile for their child. We recognize that there is no "cookie cutter" solution and all of the information that you share with Camp staff will help us to better understand your child, their challenges and how to be consistent in their care.

Please fill this form out honestly and completely.

Camper Information

*Mandatory field

*Camper First Name

*Camper Last Name

*Parent/Guardian's Name

*Parent/Guardian's Email

* Parent/Guardian Phone

Agency (if applicable)

General Information

*1. Camp is a high energy environment with a lot of people in close quarters. This may stir up behaviours that don't generally arise. Please describe any behaviours that may arise while at Camp:
AnxietyDepressionDifficulty Listening/Following InstructionsDifficulty with AuthorityHyperactivityPhysical AggressionSelf HarmTantrumsVerbal AggressionWandering/Running Away
Other:

*2a. Is there a root issue that these behaviours arise from?

b. How do we address the root issue?

*3. How does your camper relate to:

*a. their peers?
Well (no issues)Fights/argues when behaviours ariseFights/argues at any timeWants to be in charge (bossy)Submits easily to peer pressure

*b. authority figures?
Well (no issues)Argues when behaviours ariseArgues at any time

*4. All campers wake up at 7:30 am. Bedtime is between 9:30 pm and 11:00 pm, depending on age group. What are your campers' sleeping habits?

*a. Sleeps wellBed wettingStruggles to fall asleepSuffers from nightmaresWakes up frequently for the washroom

b. Regular bedtime
Regular wake up time

Triggers

*5. Are these behaviours specific to:
*a. certain situations?
Change of SurroundingsChaotic Times (lots going on around them)Down time/Unstructured TimeFeeling TeasedSudden ChangeWhen there are too many rulesWhen they aren't sure what is expected of them
* b. certain times of day?
Morning (7am-12pm)Afternoon (12pm-5pm)Evening (5pm-11pm)Any time of day
Other Comments:

*6. What are the initial signs that the behavior may start?
Agitation (talking really fast, twitching/shaking, etc.)Being LoudBeing Physical with others (pushing, poking, etc.)Withdrawal (avoiding other people)
Other Comments:

*7. Once the initial signs have started, what can we do to prevent the behavior going further?
*a. in addressing the camper:
Give them some encouragement (a pat on the back, some kind words, etc.)Ask if they would like to go for a walk with a leaderPull them aside and talk it out with them
Another prevention:
b. in the environment:
Ask the other campers to quiet downTake your camper to a calmer area
Another prevention:

Intervention

*8. If the behavior continues:
*a. what are the best words to use?:

*b. should they be separated from the group?:

*9. Consequences:
*a. should there be any consequences?
b. if so, what is the best type of consequence?
Asking them to apologizeMissing an activityScraping plates after a mealTime Out
Other Consequence:
*Note: Missing a meal (other than Tuck) will never be used as a consequence. Staff are trained to give out consequences privately.*

10. What is a positive message or action that will keep your camper in a deescalated state?

*11. What should be done if the main plan does not succeed? Who should we seek for advice?

*12. We MUST be able to contact someone regarding any issues that arise at Camp. Please provide an alternate contact to yourself who can assist us with any behaviours that arise:
Alternate Name:
Alternate Phone:

13. Do you have any further comments?

* By checking this box I indicate that I have provided the above information as accurately as possible, based on previous dealings with these challenges. If I have passed on recommendations provided to me by other professionals, these are recommendations that I as a parent/guardian support. I support the implementation of this plan by the Camp Arnes staff. I give permission to share this information with the Camp Arnes staff that are directly involved with my child.

captcha