Family Information Form

Please complete the Family Information Form in order to participate in any recommended Supporting Kidds programs and services.

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Please indicate which program or programs the Clinical Director recommended for you and your family during your consultation session: *

Guiding Pathways – Individual Counseling
Healing Pathways – 6-Week Bereavement Support Group
Healing Pathways – Single Day/Night Events
Grounding Pathways – Nature-Focused Grief Support Group
I have not completed a consultation yet

Caregiver Information

Your name: *

Relationship to child(ren): *

Who has custody of the child(ren)? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home Phone

Email *

Demographic Information

This information is used when applying for grants and aid. All identifying information is kept confidential.

Estimated Annual Household Income: *

$0-9,999
$10,000-29,999
$30,000-39,999
$40,000-49,999
$50,000-59,999
$60,000-69,999
$70,000-79,999
$80,000 & over

Child Information

Child #1 Name: *

First

Last

Child #1 Age: *

Child #1 Date of Birth: *

Layout

Child# 1 Race: *

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a/x
Native Hawaiian or Other Pacific Islander
White or Caucasian
Multi-Racial
Other

American Indian or Alaska Native Asian Black or African American Hispanic, Latino/a/x, or Spanish origin Native Hawaiian or Other Pacific Islander White or Caucasian Multi-Racial Other

Child #1 Gender: *

Female
Male
Nonbinary
Transgender
Prefer Not to Say

Child #2 Name (If Applicable):

First

Last

Child #2 Age (If Applicable):

Child #2 Date of Birth:

Layout

Child# 2 Race:

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a/x
Native Hawaiian or Other Pacific Islander
White or Caucasian
Multi-Racial
Other

Child #2 Gender (If Applicable):

Female
Male
Nonbinary
Transgender
Prefer Not to Say

Child #3 Name (If Applicable):

First

Last

Child #3 Age (If Applicable):

Child #3 Date of Birth:

Layout

Child# 3 Race:

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a/x
Native Hawaiian or Other Pacific Islander
White or Caucasian
Multi-Racial
Other

Child #3 Gender (If Applicable):

Female
Male
Nonbinary
Transgender
Prefer Not to Say

Child #4 Name (If Applicable):

First

Last

Child #4 Age (If Applicable):

Child #4 Date of Birth:

Layout

Child# 4 Race:

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a/x
Native Hawaiian or Other Pacific Islander
White or Caucasian
Multi-Racial
Other

Child #4 Gender (If Applicable):

Female
Male
Nonbinary
Transgender
Prefer Not to Say

Child #5 Name (If Applicable):

First

Last

Child #5 Age (If Applicable):

Child #5 Date of Birth:

Layout

Child# 5 Race:

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a/x
Native Hawaiian or Other Pacific Islander
White or Caucasian
Multi-Racial
Other

Child #5 Gender (If Applicable):

Female
Male
Nonbinary
Transgender
Prefer Not to Say

Additional Information

Name of Deceased *

First

Last

Relation of deceased to child(ren): *

Relation of deceased to you: *

Date of death: *

Cause and circumstance of death (Please provide details and note whether the death was sudden or expected): *

Layout

Did child(ren) witness: *

Illness
Accident
Hospital stay
Death
Funeral
Viewing of the body
Memorial service
Burial

Do child(ren) know the cause of death? *

Describe how you feel each child is coping. Note any symptoms & positive adaptations. *

List other deaths or major losses in child(ren)'s life: *

Please include name, relation to child, cause & date of death

List behavioral, learning, or health problems of each child that existed BEFORE the death. Such as, ADD, aggression, difficult to discipline, chronic illness, sibling rivalry, substance abuse, or problems with: behavior at school, learning, speech, hearing, grades, mental health, getting along with others. *

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Indicate family challenges or changes that happened BEFORE the death: *

Incarceration
Recent move
Parent substance abuse
Parent mental health problems
Parent separation
Parent divorce
Parent remarried
Step siblings
Domestic violence
Other
None

Indicate family challenges or changes that RESULTED FROM the death: *

Changes in living arrangement
Change of school
Parent working more
Change in child care
Financial hardship
Reduced contact with relatives
Strained relationship with relatives
Other
None

List 2 or 3 issues that most concern you about each child: *

List child(ren)'s allergies/sensitivities: *

Media Release

To communicate Supporting Kidds’ mission and message, to educate the community about children and grief, and report program outcomes to funders, we often use quotations, stories, artwork, and photos for brochures, newsletters, lectures, training, newspaper articles, our website, and other forms of media. Last names and detailed information are omitted from these materials.

I give permission for Supporting Kidds to use photos of my family for the purposes described above. *

I give permission for Supporting Kidds to use my family's artwork, quotations, and stories for the purposes described above. *