Client Intake Form What form are you filling out today? * Adult Intake Form Child Intake Form Adult Intake Form for Group Does the child have a parent or guardian already in our system? * Yes No Parent/Guardian First Name * Parent/Guardian Last Name * Client Information First Name * Last Name * Today’s Date Date of Birth Current Age Email Address * Phone Number * Phone Type Mobile Home Work Do we have permission to: leave voicemail send email send texts School District * School * Grade Level * Street Address * City * State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY 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 ButzerPat Ahrens How did you learn about The Grief Club? School ReferralMedical ReferralSocial MediaWebsiteFriend/Family ReferralWeb SearchCurrent ClientOrganizationOther How did you learn about The Grief Club? What group are you requesting registration for? * Death by Substance Use Disorder/Overdose GroupYoung Widow Grief Support GroupYoung Widower Grief Support Group for MenYoung Adult Grief Support GroupFamily Grief Support Group – Death of a ParentDeath of a Child Grief Support GroupFamily Grief Support Group – Death of a Sibling If you are human, leave this field blank. Next
