Let’s Talk Suicide application form Let's Talk Suicide Application form Step 1 of 4 25% I declare that the information provided by me on this application is true and accurate to the best of my knowledge and belief. I understand that misrepresentation or incorrect information provided may result in refusal of application or revocation of acceptance.* I understand and agree with the above statement and will complete this application according to these terms and conditions. Name* First Name Last Name Relationship to child (program attendee)*Please select oneMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleCase WorkerOtherOther Relation Are there any current court orders including parenting orders that we need to be aware of?* Yes No Please provide information regarding current court ordersAddress* Street Address Suburb State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile*PhoneEmail* Where do you work?* What position do you hold?* Emergency Contact DetailsName* First Name Last Name Relationship to child (program attendee)*Please select oneMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleCase WorkerOtherPrimary Contact Number*Email* Family Doctors InformationFamily Doctor Name Doctor's Contact Number Consent to contact Doctor* Yes No From time to time our Head Psychologist may need to consult with your child's Doctor. Bereavement HistoryName of deceased* Relationship to child*MotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther relation Where did they work? What position did they hold? What date did the death occur? (dd/mm/yyyy)* DD slash MM slash YYYY Does your child know that their loved one died by suicide? Yes No Where did this person die*Accident sceneCrime sceneHospitalHospiceHomeWorkOtherAdditional details surrounding death*Has the family received counselling?*YesNoHas the family received counselling? (If yes, please elaborate) Number of Children participatingHow many children are you wanting to attend the program?123456Child 1 InformationName* First Name Last Name Preferred Name Gender*MaleFemaleOtherDate of Birth (dd/mm/yyyy)* DD dash MM dash YYYY Age* 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?*YesNoPlease 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*Deceased relationship to childMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther Relation Age of your child at the time of death* Did the child witness the death?*YesNoDid the child attend the funeral/memorial service?*YesNoWhat 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?*YesNoHas the child been in any support groups or sought counselling? (yes, please elaborate)Has the child ever received mental health counselling?*YesNoHas the child ever received mental health counselling? (If yes, please elaborate)Has 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 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?*YesNoWhat 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 Let's Talk Suicide rogram?YesNoWhat, if any, concerns do you have about the child participating?*What, if any, concerns does the child express about participating?*Is there anything else we should know about the child?*Child 2 InformationName* First Name Last Name Preferred Name Gender*MaleFemaleOtherDate of Birth (dd/mm/yyyy)* DD dash MM dash YYYY Age* 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?*YesNoPlease 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*Deceased relationship to childMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther Relation Age of your child at the time of death* Did the child witness the death?*YesNoDid the child attend the funeral/memorial service?*YesNoWhat 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?*YesNoHas the child been in any support groups or sought counselling? (yes, please elaborate)Has the child ever received mental health counselling?*YesNoHas the child ever received mental health counselling? (If yes, please elaborate)Has 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 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?*YesNoWhat 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 Let's Talk Suicide rogram?YesNoWhat, if any, concerns do you have about the child participating?What, if any, concerns does the child express about participating?Is there anything else we should know about the child?*Child 3 InformationName* First Name Last Name Preferred Name Gender*MaleFemaleOtherDate of Birth (dd/mm/yyyy)* DD dash MM dash YYYY Age* 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 difficultiesIs the child known to any child protection agencies?*YesNoPlease list with whom they are registered with, along with a brief descriptionGive a brief description of this child's personalityWhat are this child's interest/hobbiesDeceased relationship to childMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther Relation Age of your child at the time of death* Did the child witness the death?*YesNoDid the child attend the funeral/memorial service?*YesNoWhat 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 deathHas the child been in any support groups or sought counselling?*YesNoHas the child been in any support groups or sought counselling? (yes, please elaborate)Has the child ever received mental health counselling?*YesNoHas the child ever received mental health counselling? (If yes, please elaborate)Has 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 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?*YesNoWhat 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 Let's Talk Suicide rogram?YesNoWhat, if any, concerns do you have about the child participating?What, if any, concerns does the child express about participating?Is there anything else we should know about the child?*Child 4 InformationName* First Name Last Name Preferred Name Gender*MaleFemaleDate of Birth (dd/mm/yyyy)* DD dash MM dash YYYY Age* Gender*MaleFemaleOtherSchool* 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 difficultiesIs the child known to any child protection agencies?*YesNoPlease list with whom they are registered with, along with a brief descriptionGive a brief description of this child's personalityWhat are this child's interest/hobbiesDeceased relationship to childMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther Relation Age of your child at the time of death* Did the child witness the death?*YesNoDid the child attend the funeral/memorial service?*YesNoWhat 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?*YesNoHas the child been in any support groups or sought counselling? (yes, please elaborate)Has the child ever received mental health counselling?*YesNoHas the child ever received mental health counselling? (If yes, please elaborate)Has 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 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?*YesNoWhat 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 Let's Talk Suicide rogram?YesNoWhat, if any, concerns do you have about the child participating?What, if any, concerns does the child express about participating?Is there anything else we should know about the child?*Child 5 InformationName* First Name Last Name Preferred Name Gender*MaleFemaleOtherDate of Birth (dd/mm/yyyy)* DD dash MM dash YYYY Age* 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 difficultiesIs the child known to any child protection agencies?*YesNoPlease list with whom they are registered with, along with a brief descriptionGive a brief description of this child's personalityWhat are this child's interest/hobbiesDeceased relationship to childMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther Relation Age of your child at the time of death* Did the child witness the death?*YesNoDid the child attend the funeral/memorial service?*YesNoWhat 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?*YesNoHas the child been in any support groups or sought counselling? (yes, please elaborate)Has the child ever received mental health counselling?*YesNoHas the child ever received mental health counselling? (If yes, please elaborate)Has 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 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?*YesNoWhat behaviour has you concerned?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 Let's Talk Suicide rogram?YesNoWhat, if any, concerns do you have about the child participating?What, if any, concerns does the child express about participating?Is there anything else we should know about the child?*Child 6 InformationName* First Name Last Name Preferred Name Gender*MaleFemaleOtherDate of Birth (dd/mm/yyyy)* DD dash MM dash YYYY Age* 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 difficultiesIs the child known to any child protection agencies?*YesNoPlease list with whom they are registered with, along with a brief descriptionGive a brief description of this child's personalityWhat are this child's interest/hobbiesDeceased relationship to childMotherFatherBrotherSisterGrandmotherGrandfatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherAuntyUncleOtherOther Relation Age of your child at the time of death* Did the child witness the death?*YesNoDid the child attend the funeral/memorial service?*YesNoWhat 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?*YesNoHas the child been in any support groups or sought counselling? (yes, please elaborate)Has the child ever received mental health counselling?*YesNoHas the child ever received mental health counselling? (If yes, please elaborate)Has 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 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?*YesNoWhat 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 Let's Talk Suicide rogram?YesNoWhat, if any, concerns do you have about the child participating?What, if any, concerns does the child express about participating?Is there anything else we should know about the child?*
