Healing Connections - Interest Form

Some kids can't find the words for what they're carrying. A paintbrush works when words don't, and so does sitting quietly next to another kid who gets it, no explanation required.

Healing Connections is a free, in-person program from the Will Trippley Foundation for kids carrying loss: death, divorce, incarceration, addiction, gun violence, a future that changed overnight. There's no pressure to talk about it. Kids create side by side, and sometimes the art says what conversation can't.

All ages and backgrounds are welcome, no art experience needed. Every material is provided, and there's never a cost to families.

Healing Connections meets the second Wednesday of each month during the school year, from 4:00 to 5:00 pm, at ACCESS: Chester Community Center, 701 Booth St., Chester, PA 19013.

If you think your child could use this space, complete the form below and we'll follow up with everything you need to know. We hope to see your family there.

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

Format: (000) 000-0000.

Can we send text messages?

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Format: (000) 000-0000.

Race/Ethnicity

What is your household income range? (Optional, for grant funding purposes)

Do you and/or your child have any experience with counseling in a group setting?

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?

Do you and others talk about the person lost?

Has your child experienced the loss of additional people?

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

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

How did you learn about Healing Connections?

Do you have any comments or questions?