PEDIATRIC GRIEF REGISTRATION FORM

PEDIATRIC GRIEF REGISTRATION FORM
Child Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Age*
Adult Caregiver Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best phone # to reach you*
Please enter a valid phone number.Format: (000) 000-0000.
*

CellHome
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
CellHome
Our grief programs are mostly grant funded. Our funders want to know the impact TJI makes in our communities and the demographics of the people we serve. The below information will only be shared as an overall program number or percentage.
Year of Birth*
Gender*
Race*
Ethnicity*
Are you currently seeing a counselor or therapist for grief support, counseling or therapy?*
Who are you seeing for counseling?*

TJI Bereavement CounselorNoneOther
Attending grief services due to death of First Name* Last Name*
Cause of death*
This person is your*

Spouse/Significant OtherParentGrandparentChildFriendAunt/UncleCousinOther
Was this person a client at TJI?
Other Losses
How did you hear about The Journey Institute Services?*

TJI served my Family/FriendsPhysicianMental Health ProviderTVRadioReputation in the communityFamily member or friendSocial MediaWebsiteOther
TJI’s Healing For Hope also offers support services for children and/or teens who are dealing with a serious illness or death of a loved one. If you would like information on these services, please select yes from below.
I would like information about grief support services for children and teens.

YesNo
Today's Date*

MonthDayYear
Date
THE BELOW SECTION IS TO BE COMPLETED BY THE JOURNEY INSTITUTE STAFF ONLY
Level of Care

GroupIndividual
Should be Empty: