Register for Family Group - Children Ages 6-9 Family Information Questionnaire General information Question Title * 1. Date Question Title * 2. Parent/guardian information: please enter name(s) and date(s) of birth (MM/DD/YYY). Question Title * 3. Address #1 Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 4. Address #2 Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 5. With whom does the child (or children) live? Question Title * 6. Do you and your child(ren) have any food allergies? Question Title * 7. Family's religious preference: Question Title * 8. Are there any special beliefs that we should know about? Question Title * 9. How did you hear about Sharing Kindness? Question Title * 10. What other programs or therapy have you used? (Select all that apply.) None Private counselor Psychiatrist School counselor Pastoral counselor Psychologist Other (please specify) About your child(ren) Question Title * 11. Please list all children in the family and place an asterisk (*) next to those who will participate in our groups. For each child, include their name, date of birth (MM/DD/YYYY), preferred pronouns and grade in school. Question Title * 12. Who currently provides the child(ren)'s primary emotional support? Mother Father Sibling Friend Relative Other (please specify) Question Title * 13. Why have you come to Sharing Kindness? (Please select all that apply.) For child(ren) to find a safe place to grieve. To help child(ren) understand death. For child(ren) to meet other kids who have suffered a similar loss. To help the family with child(ren)'s emotional problems. To help the family with child(ren)'s behavioral problems. To prevent future emotional or behavioral problems. To help adults cope. Other (please specify) Question Title * 14. Please provide any other information that you feel will help us work with your child(ren). About the deceased Question Title * 15. Details about your person: Name Relationship to child(ren) Birth date (if known) Death date Cause of death Question Title * 16. Death was: Sudden Anticipated (as with illness) Question Title * 17. Did the child(ren) witness the death? Yes No Please explain if necessary. Question Title * 18. Have the children been told everything about the death? Yes No If not, please explain. Question Title * 19. What kind of funeral and burial were chosen? Question Title * 20. Did the children attend? Yes No If not, why not? Question Title * 21. Has anyone else close to the child(ren) died? If yes: Name Age Relationship to child(ren) Death date Cause of death Was the death sudden or anticipated? Question Title * 22. Have there been any other significant losses (divorce, moving homes, pet loss, etc.) and when? Question Title * 23. Have there been any other traumatic events (e.g. major physical injuries, sudden hospital visits or frightening experiences) prior to the death? If yes, explain: Done