Family Information Form

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:

Caregiver Information

Address

Demographic Information

This information is used when applying for grants and aid. All identifying information is kept confidential.
Estimated Annual Household Income:

Child Information

Child #1 Name:
Child# 1 Race:
Child #1 Gender:
Child #2 Name (If Applicable):
Child# 2 Race:
Child #2 Gender (If Applicable):
Child #3 Name (If Applicable):
Child# 3 Race:
Child #3 Gender (If Applicable):
Child #4 Name (If Applicable):
Child# 4 Race:
Child #4 Gender (If Applicable):
Child #5 Name (If Applicable):
Child# 5 Race:
Child #5 Gender (If Applicable):

Additional Information

Name of Deceased
Did child(ren) witness:
Do child(ren) know the cause of death?
Please include name, relation to child, cause & date of death
Indicate family challenges or changes that happened BEFORE the death:
Indicate family challenges or changes that RESULTED FROM the death:

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.