Family Information FormFamily Information FormPlease complete the Family Information Form in order to participate in any recommended Supporting Kidds programs and services.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Please indicate which program or programs the Clinical Director recommended for you and your family during your consultation session: *Guiding Pathways – Individual CounselingHealing Pathways – 6-Week Bereavement Support GroupHealing Pathways – Single Day/Night EventsGrounding Pathways – Nature-Focused Grief Support GroupI have not completed a consultation yetCaregiver InformationYour name: *Relationship to child(ren): *Who has custody of the child(ren)? *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Demographic InformationThis 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 & overChild InformationChild #1 Name: *FirstLastChild #1 Age: *Child #1 Date of Birth: *LayoutChild# 1 Race: *CaucasianHispanic/LatinoAfrican/African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMulti-RacialSome OtherChild #1 Gender: *FemaleMaleNonbinary or TransgenderPrefer Not to SayChild #2 Name (If Applicable):FirstLastChild #2 Age (If Applicable):Child #2 Date of Birth:LayoutChild# 2 Race:CaucasianHispanic/LatinoAfrican/African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMulti-RacialSome OtherChild #2 Gender (If Applicable):FemaleMaleNonbinary or TransgenderPrefer Not to SayChild #3 Name (If Applicable):FirstLastChild #3 Age (If Applicable): Child #3 Date of Birth:LayoutChild# 3 Race:CaucasianHispanic/LatinoAfrican/African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMulti-RacialSome OtherChild #3 Gender (If Applicable):FemaleMaleNonbinary or TransgenderPrefer Not to SayChild #4 Name (If Applicable):FirstLastChild #4 Age (If Applicable): Child #4 Date of Birth:LayoutChild# 4 Race:CaucasianHispanic/LatinoAfrican/African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMulti-RacialSome OtherChild #4 Gender (If Applicable):FemaleMaleNonbinary or TransgenderPrefer Not to SayChild #5 Name (If Applicable):FirstLastChild #5 Age (If Applicable): Child #5 Date of Birth:LayoutChild# 5 Race:CaucasianHispanic/LatinoAfrican/African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMulti-RacialSome OtherChild #5 Gender (If Applicable):FemaleMaleNonbinary or TransgenderPrefer Not to SayAdditional InformationName of Deceased *FirstLastRelation 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): *LayoutDid child(ren) witness: *IllnessAccidentHospital stayDeathFuneralViewing of the bodyMemorial serviceBurialDo child(ren) know the cause of death? *YesNoDescribe 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 deathList 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. *LayoutIndicate family challenges or changes that happened BEFORE the death: *IncarcerationRecent moveParent substance abuseParent mental health problemsParent separationParent divorceParent remarriedStep siblingsDomestic violenceOtherNoneIndicate family challenges or changes that RESULTED FROM the death: *Changes in living arrangementChange of schoolParent working moreChange in child careFinancial hardshipReduced contact with relativesStrained relationship with relativesOtherNoneList 2 or 3 issues that most concern you about each child: *List child(ren)'s allergies/sensitivities: *Media ReleaseTo 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. *YesNoI give permission for Supporting Kidds to use my family's artwork, quotations, and stories for the purposes described above. *YesNoSubmit