Welcome to Calm Waters' In-Person Student 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 as 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 for your assistance and participation.

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* 1. Parent/Guardian Information

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* 2. Child Name

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* 3. Child Gender

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* 4. Child Age

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* 5. Child Grade

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* 6. Name of your child's school?

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* 7. Please check all losses that your child has experienced, currently or previously.

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* 8. Do any of the below apply 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 to make potential updates to our curriculum. 

In the past two weeks, how often has your child felt irritable or anxious?

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

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* 14. In the past two weeks, how has your child been eating?

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* 15. In the past two weeks, how has your child’s energy been?

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

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

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* 18. In the past month, has your child experienced bodily pain? (For example, stomachaches, headaches).

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

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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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* 33. I understand that my child will be joining a Calm Waters In-Person Student 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.

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