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Group Application

Date____________ Child’s Date of Birth__________

Child’s Age_____________

Child’s Name___________________________________________________

Male___ Female___

Address______________________________________________________________

_____________

Name of Parent or

Guardian________________________________________________________

Address

_____________________________________________________________________

_____

Home Phone___________ Cell Phone_____________ Work i

Phone___________

Emergency

Contact______________________________________________________________

Name of Person who died ____________________________________________________________

Date Person died ______________ Cause of Death _______________________________________

Relationship to the child ______________________________________________________________

Has the child been made aware of the cause of death? ___Yes ___No

Please complete the following Family History

Any History Of Please Check One Family Member Affected / Relationship to Child

Substance or Alcohol

Abuse

___Yes ___No

Mental Illness

___Yes ___No

Depression

___Yes ___No

Sexual or Physical h

Abuse

___Yes ___No

Suicide attempts or

thoughts of suicide

___Yes ___No

Please list any other deaths the child has experienced and the approximate date (friends, relatives, pets)

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__________________________________________________________________________________

Has the child received counseling in the past or currently? (if yes, please provide when and with

whom) ___Yes ___No __________________________________________________________

Has the child attended a support group in the past or currently? (if yes, please provide when and with

whom) ___Yes ___No __________________________________________________________

Is the child taking any medications? (if so, please list all medications)

___Yes ___No ________________________________________________________________

__________________________________________________________________________________

Since the death, has the child experienced any of the following?

___Yes ___No a move

___Yes ___No a change in schools

___Yes ___No grade change

___Yes ___No changes in activities

___Yes ___No changes in friends or peer interactions

___Yes ___No death of a pet

___Yes ___No divorce, separation or remarriage in the immediate family

___Yes ___No changes in sleeping patterns

___Yes ___No changes in eating habits

___Yes ___No nightmares

___Yes ___No extreme fears

___Yes ___No bed wetting

___Yes ___No temper tantrums

___Yes ___No emotional withdrawal

___Yes ___No acting out at school

About the caregiver…

What is your relationship to the deceased? ________________________________________________

Are you receiving counseling? _________________________________________________________

Are there other significant losses that you have experienced in the last 24 months? ________________

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__________________________________________________________________________________

Are there any current crises? ___________________________________________________________

__________________________________________________________________________________

How is your general health and energy level? ______________________________________________

__________________________________________________________________________________

How do others feel you are coping? _____________________________________________________

__________________________________________________________________________________

Please describe your support system? ____________________________________________________

__________________________________________________________________________________

Are there other family members who would like to attend group? If so, who and what is their

relationship to the child? ______________________________________________________________

__________________________________________________________________________________

Are there other problems or concerns you would like to share with us? _________________________

__________________________________________________________________________________

Is there any additional information we should know? ________________________________________

__________________________________________________________________________________

Please return this form to:

The Starfish Program

c/o Leslie Clemensen

Douglas County School District

620 Wilcox Street

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Castle Rock, CO 80104