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Contact Information

Email*
Confirm Email*
Phone

Caregiver 1 Information

Name*
Address
City, State, Zip
Occupation
Home Phone
Cell*
Email*

Caregiver 2 Information

Name
Address
City, State, Zip
Occupation
Home Phone
Cell
Email

Child 1 Information

Name
Age
Date of Birth (mm/dd/yy)
Grade
Allergies/Medical Conditions
What behavior changes have you seen in your child since the death? (If death occurred more than 12 months ago, please indicate if there are more recent behavior changes.)
  • Appetite
  • Mood Changes
  • Physical Symptoms
  • School Performance (Academic or Behavioral)
  • Self-Harming Behaviors (i.e. Cutting, Alcohol/ Drug use)
  • Separation Anxiety
  • Sleep Habits
  • Social Interactions
  • Not Applicable
Please describe any of the above changes.
Does your child have any learning or social needs that would be helpful for us to know? Please describe.
Medications
Purpose of Medications

Child 2 Information (If Applicable)

Name
Age
Date of Birth
Grade
Allergies/Medical Conditions
What behavior changes have you seen in your child since the death? (If death occurred more than 12 months ago, please indicate if there are more recent behavior changes.)
  • Appetite
  • Mood Changes
  • Physical Symptoms
  • School Performance (Academic or Behavioral)
  • Self-Harming Behaviors (i.e. Cutting, Alcohol/ Drug use)
  • Separation Anxiety
  • Sleep Habits
  • Social Interactions
  • Not Applicable
Please describe any of the above changes.
Does your child have any learning or social needs that would be helpful for us to know? Please describe.
Medications
Purpose of Medications

Child 3 Information (If Applicable)

Name
Age
Date of Birth
Grade
Allergies/Medical Conditions
What behavior changes have you seen in your child since the death? (If death occurred more than 12 months ago, please indicate if there are more recent behavior changes.)
  • Appetite
  • Mood Changes
  • Physical Symptoms
  • School Performance (Academic or Behavioral)
  • Self-Harming Behaviors (i.e. Cutting, Alcohol/ Drug use)
  • Separation Anxiety
  • Sleep Habits
  • Social Interactions
  • Not Applicable
Please describe any of the above changes.
Does your child have any learning or social needs that would be helpful for us to know? Please describe.
Medications
Purpose of Medications

Child 4 Information (If Applicable)

Name
Age
Date of Birth
Grade
Allergies/Medical Conditions
What behavior changes have you seen in your child since the death? (If death occurred more than 12 months ago, please indicate if there are more recent behavior changes.)
  • Appetite
  • Mood Changes
  • Physical Symptoms
  • School Performance (Academic or Behavioral)
  • Self-Harming Behaviors (i.e. Cutting, Alcohol/ Drug use)
  • Separation Anxiety
  • Sleep Habits
  • Social Interactions
  • Not Applicable
Please describe any of the above changes.
Does your child have any learning or social needs that would be helpful for us to know? Please describe.
Medications
Purpose of Medications

Information About The Person Who Died

Full Name
Date of Birth (mm/dd/yy)
Date of Death (mm/dd/yy)
Age at Death
Causes and Circumstances of death
Occupation
What was the Relationship to children?
What was the Relationship to you?

Other Information

Who told the children about the death, and what were they told? If different for any child, please describe.
Is there anything different that we should know about the death? If different for any child, please describe.
Did the children attend the wake, funeral or other ritual? If different for any child, please describe.
Are you or any of the children seeing a counselor or participating in any other support group? If yes, specify what kind of help and who is receiving it.
Have you had any recent changes in your lives, such as a move to a new location, a change in schools or work situation, divorce, remarriage?
What other losses has your family experienced within the last few years, such as the loss of other family members, friends, pets, etc. and when?
Is there a history of drug/ alcohol use or abuse in the family? If yes, please describe:
Has your family'€™s economic situation changed as a result of the death? If so, please describe.
Who else lives in your home? (Please list full name(s), age(s), and relationship(s) to your family).
Please describe your family'€™s spiritual/religious support system (if applicable).
Please describe your family'€™s support system. (Family/ friends/ neighbors, etc).
Do you own a pet? If yes, what kind?
Have you/ or your children ever thought about suicide? If yes, please describe.
If so, where is it stored and is it secured?
What are your goal's at Jeff's Place?
How did you hear about Jeff's Place?
Additional Comments

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