Center for Good Mourning Grief Support Groups Application

Registration for the Good Mourning Grief Support Groups will only be taken from the parent or legal guardian. Please make certain that you have answered all questions before submitting the completed application.

Support Group Registration

Child's Information

Child's Name:  *Preferred Name: Child's Age:  *Child's Date of Birth:  *Child's Sex:  *Child's Race:  *Child's Grade:  *Name of Child's School: Allergies to Any Food:  *If yes, please explain:  *Dirección:  *Ciudad:  *Zip:  *

Números de teléfono

Home Phone:  *Work Phone: Message Phone Cell Phone: Dirección de email:  *

Family Information

Mother's Full Name:  *Father's Full Name:  *Custodial Parent:  *

People Living in the Home

Name / Age / Relationship to Child / Job or School Grade  *Name / Age / Relationship to Child / Job or School Grade Name / Age / Relationship to Child / Job or School Grade Name / Age / Relationship to Child / Job or School Grade Name / Age / Relationship to Child / Job or School Grade Name / Age / Relationship to Child / Job or School Grade 

Background Information Regarding Death

Name of person who Died:  *Date of Death:  *Cause of Death:  *Person's relationship to child (grandfather, friend, etc.)  *Degree of pain associated with death:  *Was the death:  *Was the death violent?  *Was the child present at moment of death?  *Did the child view the dead body?  *Did the child attend the funeral / memorial service / graveside service?  *Has the child visited the grave / mausoleum since the death?  *Did the child make any expression of "good-bye" to the deceased, either on his / her own or suggested?  *On a scale of 1-5, how comfortable do you feel talking to your child about death? (1 = Not comfortable at all, 5 = Very comfortable)  *How did you explain the death to your child?  *How has the child expressed his / her grief?  *Has your child acted differently since the person died?  *What other significant deaths has your child experienced (who and when)?  *Has your child exhibited the following in the past month related to the death?
Note: 0 = Not at all, 1 = Sometimes, 2 = Very often 
Sadness:  *Depression:  *Anger:  *Shock:  *Confusion  *Panic:  *Guilt  *Resentment  *Fear:  *Alcohol/Drug Use  *Anxiety:  *Frustration:  *Relief:  *Crying:  *Irritability:  *Nightmares:  *Hopelessness:  *Loneliness  *Withdrawal:  *Poor Concentration:  *Has your child ever talked about hurting himself / herself or others  *Have there been any changes in your child's sleeping habits since the death?  *Have there been any changes in your child's appetite or eating habits since the death?  *Has your child seen a counselor to help him / her cope with the death? Does your child have any disruptive behavioral problems, including Attention-Deficit / Hyperactivity Disorder?  *Does your child know about our support group yet?  *Would your child be able to attend the next series of group sessions as listed on the website?  *If unable to attend the next series, would you like to be considered for a future series?  *How did you learn about Center for Good Mourning Support Groups?  *Please list any questions that you have about the program.

After your application is received, someone from the Center for Good Mourning will call you to review your application and discuss your questions. 
Any additional information that you think it would be good for us to know about your child and family:  *