After Care NextGen — Participant Registration & Intake Form
Participant Information
Child/Teen Full Name:
First Name
Last Name
Preferred Name/Nickname:
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Grade:
School Name:
Parent/Guardian Information
Parent/Guardian Name(s):
Relationship to Participant:
Primary Phone Number:
Format: (000) 000-0000.
Secondary Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
Emergency Contact Phone:
Format: (000) 000-0000.
Family Situation (check any that apply)
Death of a loved one
Divorce or separation
Incarcerated parent
Absent parent
Foster care or custody change
Major move or school change
Illness in family
Other:
Other
If a death occurred, who passed away?
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Relationship to participant:
Approximate date of loss:
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Emotional & Behavioral Concerns (check any noticed recently)
Frequent sadness or crying
Anger or outbursts
Withdrawal/isolating
Anxiety or worry
Difficulty sleeping
Changes in appetite
Decline in school performance
Trouble focusing
Behavior problems at home or school
Talks about missing loved one often
Does not want to talk about feelings
Other concerns:
Medical & Safety Information
Medical conditions (if any):
Allergies:
Current medications:
Currently seeing a counselor/therapist?
Has your child expressed thoughts of harming self or others?
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Participation Preferences
Participation Preferences
Quiet/Reserved
Outgoing
Slow to warm up
Unsure around new people
Things that comfort my child:
Triggers or sensitive topics:
Additional information you would like us to know:
Parent Agreements
Parent Agreements
I understand After Care NextGen is a support program and not licensed therapy.
I understand my child will never be forced to share personal experiences.
I agree to respectful behavior expectations.
I understand confidentiality will be respected, except when safety concerns arise.
I give permission for my child to participate in group activities and discussions.
I give permission for basic first aid if needed.
Parent/Guardian Signature:
Date:
-
Month
-
Day
Year
Date
Optional Permissions
Optional Permissions
I allow my child to receive prayer and faith-based encouragement.
I allow my child to receive provided snacks.
I allow my child to participate in creative activities (art, journaling, group exercises).
Photo Release: I allow non-identifying photos for promotional purposes.
Signature:
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