Healing Connections - Interest Form

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. These sessions, held on the fourth Wednesday of each month at 4 PM at the ACCESS Chester Community Center (701 Booth Street, Chester, PA 19013), provide a safe and supportive space 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

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?