School Registration 2019-2020 Survey

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* 2. Child Information

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 3. Child Gender

Male

Female

Prefer not to answer

Other (please specify)

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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.

Death

Divorce/Separation

Foster care/Adoption

Deportation of a loved one

Incarceration of a parent/guardian

Military service of a parent/guardian

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

Active Duty Military

Military Dependent

Veteran

None apply

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* 9. Annual Family Income

0-20,000

20,001-40,000

40,001-60,000

60,001-80,000

80,001-100,000

over 100,000

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

Asian/ Pacific Islander

Black/ African American

Caucasian/ Anglo

Hispanic/ Latin

Native American

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

Therapist/Counselor

Friend/Acquaintance

Teacher/School counselor

Doctor or other medical professional

Attorney

Other (please specify)

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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 irritable or anxious?

Nearly everyday

More than half of a seven-day week

A few days

Not at all

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

Pour (less than 3 hours)

Fair (5 hours or less)

Good (6 to 7 hours)

Excellent (8 hours or more)

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

Poor

Fair

Good

Excellent

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

Poor

Fair

Good

Excellent

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

Yes

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

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* 18. In the past month, did your child try a substance like alchohol or drugs?

Yes

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

Poor

Fair

Good

Excellent

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* 20. In the past two weeks, has your child felt alone with their loss?

Very alone

Slightly alone

Slightly supported

Very supported

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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* 31. 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?

Yes

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* 32. 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)?

Yes

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* 33. 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.
*If you are a School Counselor or School Facilitator you can only sign your name with a physical copy of the guardians consent.

School Registration 2019-2020

Welcome to Calm Waters' School Support Group Registration

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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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* 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 overall health?

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

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

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* 18. In the past month, did your child try a substance like alchohol or drugs?

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

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* 20. In the past two weeks, has your child felt alone with their loss?

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

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* 22. 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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* 23. 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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* 24. 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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* 25. At any point since your child was born, have they been in foster care?

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

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* 27. 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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* 28. 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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* 29. At any point since your child was born, has your child had a serious medical procedure or life threatening illness?

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

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* 31. 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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* 32. 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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* 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.