In-Person Student Grief Support Groups (School Year 2020-2021) Survey

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* 1. Parent/Guardian Information

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Child Name

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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 Grade

Pre-K

Kindergarten

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

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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.

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 apply 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 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 has your child been sleeping?

Poor (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 has your child been eating?

Poor - Does not eat much at meals or at other points throughout the day.

Fair - Does not eat much at meals, but will snack throughout the day.

Good- Eats well at meals, some snacks.

Excessive - Frequently overeats at meals and snacks often.

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

Low - Tired often, unable to enjoy or complete tasks.

Fair - Tired, but manages to get tasks done.

Good - Energy level seems typical for age.

Excessive - Overly energetic for what seems typical.

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

Poor - Gets sick frequently and struggles to recover.

Fair - Gets sick, but recovers quickly.

Good - Occasional cold/allergies, but generally healthy.

Excellent - Rarely gets sick.

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

Poor - Never appears happy.

Fair - Rarely appears happy.

Good - Often appears happy.

Excellent - Frequently appears happy.

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

Yes

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

Yes

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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 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.

In-Person Student Grief Support Groups (School Year 2020-2021)

Welcome to Calm Waters' In-Person Student Support Group Registration

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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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* 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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