Healing Connections - Interest Form

Healing Connections
Healing Connections is a monthly, in-person program offered by the Will Trippley Foundation to help children navigate various types of loss—whether it's the passing of a loved one, separation from a caregiver, or other life-changing events—through artistic expression and shared understanding. Held at the Downtown CAAT Center, located at 515 Avenue of the States in Chester, PA 19013, these sessions provide a safe and nurturing community for kids to connect with peers who truly understand their experiences.

Our registration is always open, and children of all ages and backgrounds are encouraged to join, regardless of art experience. The program is completely free, and all materials are provided. If you feel your child could benefit from Healing Connections, please complete the form below. We’ll reach out with more details and look forward to supporting your family on this healing journey.
Parent/Guardian Name*

First NameLast Name
Child Name (Please complete form for each individual child)*

First NameLast Name
Age of Child*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian E-mail Address*
example@example.com
Primary Contact Number*
Can we send text messages?*

YesNo
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number *
Race/Ethnicity*

African AmericanHispanicNative AmericanMiddle EasternNative Hawaiian/Other Pacific IslanderAsianCaucasianOther
What is your household income range? (Optional, for grant funding purposes)

$0 - $25,000$25,001 - $50,000$50,001 - $75,000$75,001 - $100,000$100,001+Prefer not to say
Do you and/or your child have any experience with counseling in a group setting?*

YesNo
If yes, please explain and list any concerns you may have:
What concerns, if any, do you have about your child attending this program?
Bereavement History
Name of person lost*
Relationship to person lost*
Date of Loss:*
Cause of Loss:*
Does your child have memories of the person lost?*

YesNo
Do you and others talk about the person lost?*

YesNo
Do you and others talk about the person lost?*

YesNo
Has your child experienced the loss of additional people?*

YesNo
Has your child received any professional support? (Support group, psychologist, school counseling)*

YesNo
Describe the majority of your child's memories of the person lost:*

All Positive MemoriesMostly Positive MemoriesMostly Negative MemoriesAll Negative Memories
How did you learn about Healing Connections?

Past participantThe Trippley Foundation's Facebook pageA Trippley Foundation Board MemberThe Trippley Foundation's Instagram pageThe Trippley Foundation's newsletterThe Trippley Foundation's LinkedIn pageFamily member and/or friendSchoolAnother organizationOther
Do you have any comments or questions?
Should be Empty: