Stepping Stones Through Grief REGISTRATION FORM

Stepping Stones Through Grief
REGISTRATION FORM

Enrollment is limited!

Date:

How did you hear about this group?

Child’s Name:

Gender:

Male

Female

Address:

City: State: Zip:

Email Address:

Date of Child’s Birth:

Name and ages of brothers and/or sisters:

Telephone: Daytime: Evening:

Adult Contact’s Name:

Relationship to child:

Address:

Telephone: Home: Work:

Information about the person who died:

Name of person(s) who died and relationship to you:

Name:

Relationship to child:

Did this person live with child?

Yes

Date the death occurred:

Circumstances surrounding the death:

How has the child been doing since the death?

Have you noticed any behavior changes since the loss?

Other Major Losses? Include the name and date please.

Is the child under the care of a therapist/counselor?

Yes

Is the child currently taking medication?

Yes

Does the child have any allergies?

Yes

Emergency Contact:

Name:

Relationship to child:

Address: City:

State: Telephone:

Additional Comments:

• I can make a commitment to attend all eight weeks of the group:

Yes

• I cannot attend at this time, however I would like to be notified when the next group starts.

Yes

Please call the hospice program at the Visiting Nurse Hospice 622-3781 with any questions.

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