Children's Grief Support Group Interest Form
(In-Person)
Child Name
*
First Name
Last Name
Age
Grade
Caregiver Name
First Name
Last Name
Relationship to Child
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
About the Loss
Who did your child lose?
Approximately when did the loss occur?
Has your child participated in grief counseling before?
*
Please Select
Yes
No
Current Concerns
What changes have you noticed in your child since the loss?
What are you hoping your child will gain from this group?
Screening Questions
Is you child currently receiving therapy?
Has your child expressed thoughts of self-harm?
Is there anything important we should know to support your child in a group setting?
Group Scheduling Preference (This group will meet either:)
Saturday mornings
Saturday afternoons
Weekday evenings
No preference
Screening Call Availability (Please select the time you are available for a brief 15-20 minute screening call:
Weekday mornings (9am-12pm)
Weekday afternoons (12pm-4pm)
Weekday evenings (5pm-7pm)
Saturday morning
Saturday afternoon
Other
Acknowledgement
*
I understand this form expresses interest only and a brief screening call is required before enrollment.
*
I understand group placement is determined after screening to ensure the group is an appropriate fit.
Signature
Date
-
Month
-
Day
Year
Date
Contact Information
Jasmine Evans, MSW, LSW | (557)-208-0266 | j.evans@thecommunityreach.org
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