Healthy Grieving Program Application – Step 4 Child 1 Healthy Grieving Program Application - Step 4.1 Child 1 Child 1 InformationName* First Name Last Name Preferred Name HGP Program Dates*Please select your preferred dates (you can select more then one date) and the age category the child is at the time of the preferred program date. Program Two 10-13 years - Saturday 19th and Sunday 20th June – HGP.P2 Program One 7-9 years - Saturday 26th and Sunday 27th June – HGP.P1 Program Three 14-17 years - Saturday 7th and Sunday 8th August – HGP.P3 Program Two 10-13 years - Saturday 28th and Sunday 29th August – HGP.P2 Program One 7-9 years - Saturday 11th and Sunday 12th September – HGP.P1 Program Two 10-13 years - Saturday 9th and Sunday 10th October – HGP.P2 Program Three 14-17 years - Saturday 13th and Sunday 14th November – HGP.P3 Program One 7-9 years - Saturday 15th and Sunday 16th January 2022- HGP.P1 Program Two 10-13 years - Saturday 22nd and Sunday 23rd January 2022 – HGP.P2 Gender*Please select oneFemaleMaleD.O.B*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age* School* School Grade* Main Language Spoken At Home* Does this child have any medical, disability or learning difficulties (Check all that apply)* ADD ADHD Anaphalaxis Anxiety ASD Asthma Bipolar Conduct Disorder Cystic Fibrosis Depression Diabetes Epilepsy Learning Disorder ODD Other N/A Please provide further information regarding any medical, disability or learning difficulties*Is the child known to any child protection agencies*Please select oneYesNoPlease list with whom they are registered with, along with a brief descriptionGive a brief description of this child's personality*What are this child's interest/hobbies*What do you want this child to learn from this program?*Deceased relationship to child*Please select oneMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther Relation Age of your child at the time of death* Did the child witness the death?*Please select oneYesNoDid the child attend the funeral/memorial service?*Please select oneYesNoWhat were your child’s reactions to/comments about the service?Describe in detail the child’s relationship with the deceased and how his or her life has been affected by the death*Has the child been in any support groups or sought counselling?*Please select oneYesNoHas the child been in any support groups or sought counselling? (yes, please elaborate)Has the child ever received mental health counselling?*Please select oneYesNoHas the child ever received mental health counselling? (If yes, please elaborate)Name of Mental Health Professional Contact Number of Mental Health Professional Mental Health Professional's Contact Email Address* Consent to contact child’s mental health professional?*YesNoFrom time to time our Head Psychologist may need to consult with your child's Psychologist / CounsellorHas the child exhibited any of the following behaviours since the death? (Check all that apply)* Attempted suicide Bed wetting Behavioral problems at home Behavioral problems at school Changes in friends Changes in grades Depression Destruction of property Discussed suicide Drug/alcohol use Exhibiting behaviors younger than their age Getting into fights Harmed others Harmed self Increased physical illness Intense anger Intense clinging or longing Intense guilt Involvement with the police/law enforcement Isolates self or spends excessive time alone Lying Mental health concerns Nightmares Ongoing sleep problems Run away from home Stealing Unusual fears Unusual/inappropriate sexual behaviour None of the above If yes to any of the above, please elaboratePlease explain how the child expresses grief and what triggers emotions such as: Anger, Sadness, Depression, etc.*Has the child experienced any of the following? (Check all that apply)* Change in friendship groups Change of school Divorce of parents/guardians Friends or family have become distant Major illness Major illness of family member New house/Moving Other deaths Separation of parents/guardians None of the above If yes to any of the above, please elaborateHas the child said or done anything recently that has concerned you?*Please select oneYesNoWhat behaviour has you concerned?How does your child connect with and relate to peers?*Have you and the child talked about him/her participating in the Healthy Grieving Program?*Please select oneYesNoIs there anything else we should know about the child?*Click here to apply for another Child Apply for Child 2
