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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
Nickname
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

Contact Information

Address
Street Address
City State Zip
Phone Numbers
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--
Home Phone Work Phone
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Message Phone Cell Phone
Email Address

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

Background Information Regarding Death

Name of person who died
Date of death
Cause of death
Person’s relationship to child (grandfather, friend, etc)
Age of person who died
Degree of pain associated with death
Was the death:
If expected, for how long?
Was the death violent?
If yes, please describe if the child either heard about or witnessed the violence personally.
Was the child present at moment of death?
If yes, please describe circumstances including who else was present and whether the deceased said anything specifically to child.
Did the child view the dead body?
If yes, please describe circumstances including reactions of the child and others who were present.
Did the child attend funeral/memorial service/graveside service?
Which? Child’s reaction?
Has the child visited grave/mausoleum since the death?
If yes, describe circumstances.
Did the child make any expression of “good-bye” to the deceased, either on his/her own or suggested?
If yes, describe.
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)
Not at all comfortable Somewhat comfortable 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?
If yes, please describe how.
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
Anxiety
Depression
Frustration
Anger
Relief
Shock
Crying
Confusion
Irritability
Panic
Nightmares
Guilt
Hopelessness
Resentment
Loneliness
Fear
Withdrawal
Alcohol/Drug Use
Poor Concentration
Has your child ever talked about hurting himself/herself or others?
If yes, please explain.
Have there been any changes in your child’s sleeping habits since the death?
If yes, please explain.
Have there been any changes in your child’s appetite or eating habits since the death?
If yes, please explain.
Has your child seen a counselor to help him/her cope with the death?
If yes, who and where?
Does your child have any disruptive behavioral problems, including Attention-Deficit/Hyperactivity Disorder?
If yes, please explain.
Does your child know about our support group yet?
Please describe what he/she thinks about attending.
Would your child be able to attend the next series of group sessions as listed on the website?
If no, please explain.
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:

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