Healthy Grieving Program Application – Step 4 Children's details

Child's Information

Name*

First Name Last Name

Preferred Name

Healthy Grieving Program dates

Let's Talk Suicide Program Dates

Gender*

D.O.B*

Age*

School*

School Grade*

Main Language Spoken At Home*

Does this child have any medical, disability or learning difficulties (Check all that apply)*

Please provide further information regarding any medical, disability or learning difficulties*

Is the child known to any child protection agencies*

Please list with whom they are registered with, along with a brief description

Give 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*

Other Relation

Age of your child at the time of death*

Did the child witness the death?*

Did the child attend the funeral/memorial service?*

What 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?*

Has the child been in any support groups or sought counselling? (yes, please elaborate)

Has the child ever received mental health counselling?*

Has 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?*

From time to time our Head Psychologist may need to consult with your child's Psychologist / Counsellor

Has the child exhibited any of the following behaviours since the death? (Check all that apply)*

If yes to any of the above, please elaborate

Please 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)*

If yes to any of the above, please elaborate

Has the child said or done anything recently that has concerned you?*

What 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?*

Is there anything else we should know about the child?*

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Healthy Grieving Program Application – Step 4 Children’s details

Virtual Camp Program Application - Step 4.1 Child application

Child's Information