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Information & Registration |
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Child or Adolescent Support Group Client Information & Registration Form
(Please complete a registration and information form for each child attending a support group)
Date: ______________________________
Name of person completing this form: _____________________________
Relationship to child/adolescent: _________________________________
Daytime Contact #: ________________ Alternate Phone #: _________________
Mailing Address:
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Place of Work: _____________________________________
Work Phone: __________________
Occupation:
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How did you find out about My Healing Place?
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What brings you to My Healing Place at this particular time?
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_________________________________________________________________ (if additional space is needed please feel free to write on the back side of this form)
What would you like your child(ren) to gain through participation in a grief support group at this time?
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Name of child/adolescent: __________________________________
Date of Birth (xx-xx-xxxx): _____________________
Current Grade in school: ______________________
What school does your child attend? ______________________in _____________ School District
Emergency Contact Person
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Emergency Contact Phone #:_____________________________
Is the loss a death loss? Yes No If yes, what is your child’s relationship to the deceased? (i.e. son, sister, etc.)
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Is the loss a non-death loss? Divorce Separation Abuse Job related Incarceration
Deployment Assault Abandonment Other: _____________
Please describe the circumstances of the loss that brings you to My Healing Place. If this is a death loss please describe the cause of death and circumstances of the death.
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When did this loss occur? (give date if applicable)__________________________
How did your child find out about the loss?
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If possible, write down the “verbage” used to explain the loss to your child.
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If the loss is related to a person, please describe your child’s relationship to this person.
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If this is a death loss, in what aspects of the rituals following the death did your child participate? (i.e. visitation, funeral, etc.)
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What questions or comments has your child made about this loss?
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Please list any other significant losses (death and non-death) your child has experienced.
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List the persons who live in the home with your child.
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Who are the people/groups who support your child?
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Please place a check mark beside any of the following you have observed in your child:
___difficulty sleeping ___easily frustrated ___inability to concentrate
___difficulty getting up in the a.m. ___heightened level of irritation
__high levels of anxiety ___nightmares ___anger outbursts ___ fatigue
___ changes in appetite ___ easily startled ___ frequent crying
___ stomach aches ___ headaches ___ withdrawn ___clinginess
Has your child ever participated in counseling or therapy for any reason? ______ If yes, briefly describe the reasons for seeking help and the outcome of the therapy?
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Is your child currently under the care of a physician? __________ If yes, please give us the name and phone number of the physician.
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Please list any prescription medication your child is currently taking. _________________________________________________________________
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Please tell us anything else that may be helpful for us to know about your child and your situation as he/she participates in grief support at My Healing Place.
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