• Support Group Intake Questionnaire

    Complete one form per family. A member of the One Million Monarchs team will contact you to schedule an intake call once we receive your completed questionnaire. **Our support groups currently meet in Cary and Crystal Lake, Illinois** If you are outside this service area and would like assistance, please select the "Virtual" option and we will contact you to help you find a support group in your area. As our program grows, we will add new sites and locations and if there is enough need, we may add virtual support groups via Zoom.
  • Support Group Location

  • Family Information

    At this time we are only staffed to support Teens (age 13-19). If you have younger children who need support, please fill out their information and we will help you find appropriate resources or waitlist them in the event we open up the program to younger children.
  • Child 1

  • Child 2

  • Child 3

  • Child 4

  • Adults living with child(ren)

  • Adult 1

  • Adult 2

  • If children are not living with joint custodial parent, please list their information:

  • Emergency Information
    (Someone other than the custodial parent)

  • Demographics

    Why do we ask? We rely on various funding sources to run our programs and on occasion, this information is helpful in securing grants or special funding.
  • Questions about the person who died

  • I understand that One Million Monarchs offers peer support to my family.  My family and I are here to share our experiences of death with others who have experienced a death.  I understand that One Million Monarchs support groups are not counseling, and do not offer therapy, counseling, assessments or evaluations. 

    You should not participate in group support services other than on a voluntary basis. You have the right to withdraw from the group at any time. We ask that you inform the group facilitator if you no longer plan to attend the group.

    By signing below I hereby release and discharge One Million Monarchs, its officers, employees, volunteers, agents and assigns (the “Released Parties”) from any and all claims which may arise from any cause whatsoever in connection with my participation in these group support services. I further release the Released Parties from any liability for any accident, illness, injury, death, loss or damage to personal property, or any other consequences arising or resulting directly or indirectly from my participation in the group support services. I acknowledge the Released Parties assume no responsibility for any liability, damage, injury or death that may be caused by my negligent or intentional acts or omissions committed prior to, during, or after participation in the group support services, or for any liability, damage, injury or death caused by the intentional or negligent acts or omissions of others. I agree to indemnify, defend, and hold harmless the Released Parties from any injury, loss or liability including reasonable attorneys’ fees and/or any other associated costs, from any action, claim, or demand in connection with my participation in the group support services.

    I also agree to ensure that my family conforms to all health and safety precautions as it relates to the Covid-19 pandemic.  This includes agreeing to wear a face mask while on site as well as to abstain from attending group if you or your family exhibits any symptoms of the virus or has been in close prolonged contact with a person who has tested positive for Covid-19.  I agree to allow One Million Monarchs to conduct a temperature check and visual assessment to ensure that I am in good health prior to attending group. A temperature exceeding 99.9 gives One Million Monarchs reasonable cause to ask a participant to abstain from attending group that week.

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