Children’s Counseling Assessment
*Please note that if you have previously filled out this form for one of our previous Children’s Grief Program events, you do not have to fill this out again unless you have updated information to provide.
About the Child
Child's First Name
*
Last Name
*
Date of Birth
/
Month
/
Day
Year
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Gender
Height & Weight
Upload a closeup photo of your child like the one shown (to be used for identification purposes only)
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Health History
Please check all that apply:
Attention Deficit Disorder
Asthma
Ear Infection
Fainting
Wears Glasses
Acquired Immune Deficiency Syndrome
Constipation/Diarrhea
Fears/Phobias
Hepatitis
Kidney Disease
Menstrual Cramps
Developmentally Delayed
Nosebleeds
Emotional Problems
Convulsions/Seizures
Diabetes
Hearing Impairment
ADHD
Allergies
Motion Sickness
Heart Disease
Wears Contacts
HIV
Sickle Cell Anemia
Nightmares
Special Dietary Needs
Other (please explain)
Please explain any information we may need to know to care safely for your child.
Are there medications your child may need to carry or take?
Food allergies (please provide severity of food allergies, reactions and any other information)
Drug allergies (please provide severity of allergies, reactions and any other information)
Pet or animal dander allergies (please provide of allergies, reactions and any other information)
Other significant allergies
Please list any dietary restrictions (physician recommended/religious, etc.)
Are there any activities your child may not be able to participate in while attending our services?
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No
Yes (please explain)
Have there been any other changes or stressful situations in your child’s life such as divorce, illness, recent move, multiple losses, etc.? Please describe.
Has your child experienced any behavioral problems you believe may be related to the death?
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No
Yes (please explain)
Does your child have difficulty with any of the following areas? If yes, please explain.
Rows
Check if yes
Please explain
Sleeping?
Eating?
School?
Relationships?
Are there any language, disability, or other needs, family customs, or cultural aspects to your child’s grieving that we should be aware of?
What are some ways your child expresses their grief or emotions related to their loss? (Ex: acting out, increased clinginess, questions about the death or avoiding discussion)
Are there any specific concerns or challenges your child is currently facing in their grief journey that you would like our team to be aware of?
Is there anything else you would like us to know about your child’s personality, preferences, or comfort needs to help us best support them during our programming?
Is your child currently receiving counseling? If so, please explain the primary purpose.
About the Deceased
Name of the deceased
*
Age of person who died
*
Relationship to the child
*
Date death occured
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Month
/
Day
Year
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Age of child at time of loss
*
Cause of death
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Briefly describe the relationship between the child and the deceased.
Did the child reside with the person who died?
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Yes
No
Other
Did the child witness the death?
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Yes
No
Was the child present at the funeral/memorial?
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Yes
No
Is there anything specific that you feel would be helpful for our team to know relating to the death and your child?
Authorizations and Permissions
Parent/Guardian: Please read all authorizations and permissions required and provide your signature where indicated. Your authorization must be granted in order for your child to begin services.
I hereby authorize Angela Hospice Home Care, Inc., and its staff to supervise and instruct my child in all Children’s Grief Program activities. I am aware of the nature of the Children’s Grief Program activities and any brochure, flyer or announcement relating to such activities is expressly incorporated by reference into this document. I hereby give my unqualified permission for my child to participate in all children’s grief activities, for which he or she may qualify under program standards. I am aware that there are inherent risks in the activities and particularly in situations that involve physical activity, there may be a risk of injury. I understand that Angela Hospice does not provide accident or health care insurance for my child and that I am responsible for this insurance. I understand that it is my responsibility to inform Angela Hospice of all physical limitations, liabilities or injuries involving my child, including without limitation, neck and back problems, recent surgery, allergies and any other medical situations.
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Yes
In the event of emergency, I hereby authorize the staff of Angela Hospice to administer first aid and/or obtain emergency medical treatment (911) as determined by Angela Hospice Staff, including as necessary transportation for such treatment. This treatment may include routine tests and z-rays. I understand that in the event of an injury or other medical problem, Angela Hospice staff shall make every effort or notify my or a person I have identified as alternate contact person as soon as possibleand subject to the need in a particular circumstance, to make an immediate decision regarding any such first aid and/or emergency medical treatment. Angela Hospice staff shall refer all non-emergent decisions related to the medical care of my child to me or my alternate contact person.
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Yes
I understand that Angela Hospice shall not be responsible or liable for the loss of personal property or any consequence of personal injury sustained by my child. This includes, but is not limited to, personal injury or loss of personal property sustained while participating in off-site activities. I hereby do indemnify and hold harmless Angela Hospice Home Care, Inc., from any loss, claim, or expense (including attorney’s fees) incurred by Children’s Grief Programming but not caused by its negligence, arising from the personal injury of or loss of personal property by my child during any children’s grief programming.
*
Yes
I hereby grant to Angela Hospice Home Car Inc., and its legal representative the right and unrestricted permission to use and publish photographs or video images of my child from this event, or in which my child may be included, for any purposed authorized by Angela Hospice Home Car., Inc., including but not limited to: website use, editorial publications, broadcast media (radio, television), literature and advertising use. This grant includes the right to modify and retouch the images at the discretion of Angela Hospice Home Car, Inc., I understand that the circulation of such materials could be worldwide and there will be no compensation to me for this use. I understand that I will not be given the opportunity to inspect or approve the finished products or the advertising copy or the printed matter that may be used in connection therewith.
*
Yes
No
Permission for Counselor
MSW Grief Counselors will be providing supportive services to children participants. Except for emergency evaluations, parents or guardians need to provide consent in order for counselors to intervene with their child. By signing below, you are providing your consent for your child to speak with a grief counselor if he/she desires. The counselors will be supportive listeners and provide an opportunity for your child to talk about his/her life experiences. If a mental health emergency were to arise, these counselors will be available to assess the children and advise necessary measures.
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Yes
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Signature
*
Date
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Month
-
Day
Year
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Hour Minutes
AM
PM
AM/PM Option
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Alternative Contact Information
Please provide an alternative contact for your child in the event that contact is not able to be made with primary parent/guardian.
Name of Alternative Contact
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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