FCPS Request Form for Individual Bereavement Counseling Services
Bereavement counseling services are intended as short-term counseling for students following the death of a family member or other loved one. The counseling services offered are specific to issues related to grief and loss and are not meant to replace behavioral/mental therapy issues.
Date
-
Month
-
Day
Year
Date
FCPS School
Referred by
Email
example@example.com
Phone
CASS Coordinator Assigned to School
Guardians/Parents are:
Married
Single
Divorced
Never Married
Is there a court order that establishes custody/guardianship?
Yes
No
Legal Guardian Name
Email
example@example.com
Relationship
Work/Cell Phone(s)
Student's Legal Name
Date of Birth
/
Month
/
Day
Year
Date
Gender (as identified by student)
Race
Requested/Preferred Name
Pronouns
Does the student speak English?
Yes
No
Student's Primary Language
Does the family need an interpreter?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Assigned School
Grade
Does the student currently have a behavioral/mental health therapist?
Yes
No
First/Last Name of Deceased
Relationship to Student
Date and Cause of Death
Comments
A Bereavement Coordinator will reach out to you soon.
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