Beyond Akeela Application: 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 teen post-secondary transition program, Beyond Akeela. (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 (

    Beyond Akeela is a three week overnight summer program for teens who are working on their college readiness as their post-secondary education approaches. Our mission is to provide our campers with a summer filled with fun, friendship, and personal success and growth. Our focus is on the essential non-academic social, independent living, and organizational skills teens needs to be successful in college settings. There is also a travel element to the program in which the campers follow a schedule similar to that of a teen tour. 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 teen interact with peers? (Give examples if possible.) If you've never seen this teen with his/her/their peers, how does he/she/they describe these interactions to you?

    Does he/she/they enjoy the company of others?

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

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

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

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

    Your Electronic Signature:

    (Please type your name.)

    Please type the code shown in the image.


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