Heritage Academy Counselor or Administrator Evaluation
Applicant’s Name _________________________________Applying for Grade________
Counselor or Administrator Evaluation
Name of person completing this report: _______________________________________________________________
Name of school: _________________________________________________________________________________
1. I have known the above applicant for __________________ as his/her __________________________________
2. This report is based on: _____ Personal observation and contact with student _____ Teacher Comments ________
Other counselor’s observations _____ Records ____ Other (explain) _______________________________
3. The student has been sent to the office for disciplinary reasons: ____ Often ____ Seldom ____ Never
Please describe problem(s) ________________________________________________________________________
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4.This student has been suspended _____ times. Reason(s) _____________________________________________
5. Has the applicant been expelled or dismissed from school for academic or disciplinary reasons and therefore not
eligible to return? ____ Yes ____ No Explain: __________________________________________________
6. Do you have any reason to doubt this student’s academic integrity? ________ Yes _______ No
7. The applicant’s attendance has been: ______ Excellent _____ Good _____ Poor
8. The applicant’s parents can best be described as: (Circle as many as apply)
Involved Cooperative Difficult Uninvolved
Tends to blame school for student’s problems
9. Does the applicant have any significant limitations (physical, social/emotional, academic/learning disabilities)
Please describe: __________________________________________________________________________
________________________________________________________________________________________
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