Welcome to Calm Waters' School Support Group Registration

The mission of Calm Waters is supported by grant funding and individual donations. Most grantors request demographic information about Calm Waters participants, such a age, gender, race and income. This grant funding allows Calm Waters to continuously provide FREE grief support services to children and families in their grief journey caused by death, divorce or other significant loss. 
Thank you so much for assistance and participation.

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* 1. Parent/Guardian Name

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* 2. Child Information

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* 3. Child Gender

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* 4. Child Age

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* 5. Child school grade

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* 6. Name of your child's school?
*Please note, your child's school counselor will receive this registration and contact you before group begins. If your child's school does not participate in the Calm Waters' School Support Group program, please consider registering for a Center Support Group.

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* 7. Please check all loss issues that apply for your child, currently or previously.

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* 8. Do any of the below options to your household?

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* 9. Annual Family Income

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* 10. Child Ethnicity: Please select all that apply.

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* 11. How did you hear about Calm Waters' Center for Children and Families School Support Groups?

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* 12. The following questions are the pre-group survey. After the support group is complete, Calm Waters staff will email you a post-group survey, allowing us to see the improvement your child has made within their support group, and allows us to make potential updates to our curriculum. 

In the past two weeks, how often has your child felt down, depressed or hopeless?

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* 13. In the past two weeks, how is your child sleeping?

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* 14. In the past two weeks, how is your child’s energy?

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* 15. In the past month, how would you rate your child’s health?

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* 16. In the past month, how much bodily pain has your child experienced?

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* 17. In the past month, how much has your child been affected by emotional problems (such as feeling anxious, depressed or irritable)?

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* 18. How many days in the past month has your child missed school?

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* 19. Did your child begin trying drugs or alcohol after the loss?

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* 20. In the past two weeks, how would you rate your child's overall happiness? 

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* 21. In the past two weeks, how alone has your child felt in their loss? 

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* 22. At any point since your child was born, have your child's parents or guardians experienced separation/divorce?

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* 23. At any point since your child was born, has your child lived with a household member who has served time in jail or prison?

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* 24. At any point since your child was born, has your child lived with a household member who was depressed, mentally ill or attempted suicide?

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* 25. At any point since your child was born, has your child lived with someone who had a problem with drinking or drugs?

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* 26. At any point since your child was born, have they been in foster care?

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* 27. At any point since your child was born, has your child experienced harassment or bullying at school?

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* 28. At any point since your child was born, has your child had a parent/guardian and/or loved one who died?

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* 29. At any point since your child was born, has your child been separated from their primary caregiver through deportation or immigration?

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* 30. At any point since your child was born, has your child had a serious medical procedure or life threatening illness?

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* 31. At any point since your child was born, has your child been detained, arrested or incarcerated?

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* 32. At any point since your child was born, has your child often been treated badly because of race, sexual orientation, place of birth, disability or religion?

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* 33. At any point since your child was born, has your child experienced verbal or physical abuse or threats from a romantic partner (boyfriend or girlfriend)?

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* 34. I understand that my child will be joining a Calm Waters School Support group. I understand that this is a support group and not a counseling group. I understand that this group is led by trained volunteers and attendance in this group is optional. 

If you consent for your child to attend this support group, please type your full legal name.

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