Child Group Intake Form Child Group Intake Form Does the child have a parent or guardian already in our system? No Yes What group are you requesting registration for? Parent/Guardian First Name * Parent/Guardian Last Name * Parent/Guardian First Name Email Address * Parent/Guardian Information arrowup6 First Name * Last Name * Email Address * Phone Number * How did you learn about The Grief Club? School ReferralMedical ReferralSocial MediaWebsiteFriend/Family ReferralWeb SearchOther How did you learn about The Grief Club? Street Address * City * State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Postal Code * Child Information arrowup6 First Name * Last Name * Today’s Date Date of Birth Current Age School District * School * Grade Level * Street Address * City * State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Is the child’s address the same as above? Yes No Postal Code * Race & Ethnicity * American Indian or Alaska Native Asian Black / African-American Caucasian / White Hispanic or Latinx Native Hawaiian or Other Pacific Islander Prefer not to answer Other If Other Who is your counselor * Please ChooseNone yetAllison ChantCara Mearns-ThompsonEmily BrocatoSarah KroenkeLindsay Butzer Agreement I hereby grant permission to the Grief Club to use photographs and/or video of me and my child(ren) in publications, news releases, online, and in other communications related to the mission of the Grief Club. Emergency Contact Information – if different from above arrowup6 First Name Last Name Phone Relationship to Client Additional Information arrowup6 Name of person who died * Relationship to Client * ChildMotherFatherParentStepmotherStepfatherSiblingSpouse/PartnerOther Age of the person who died: Age of client at time of death Was the client present? Yes No Date of birth * Date of death * Location of death Cause of death * AccidentHealth/MedicalOverdoseSuicideOther Send Form If you are human, leave this field blank.
