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Home
About Us
History
Leadership
Health Professionals
Community Partnerships, Companies & Foundations
Committed to Excellence
Privacy Practices and Medical Records
Annual Reports
Services
Workplace Wellness
Flu Vaccination
Flu Clinic Request Form
Medical Foot Care
CAPABLE
Home Health Care
Hospice Care
Hospice Care FAQ
Grief Support
Grief Support Groups & Events
Grief Support Registration Form
Donate
Caregiver Recognition
Volunteer
Join Our Team
Nursing Assistant Training
News & Blog
Contact Us
Child/Teen Intake Form
Grief Counseling Intake Form - Child/Teen
Parent/Guardian Name
First
Last
Address Line 1
Address Line 2
City
State
Zip Code
Home Phone
Work Phone
Mobile Phone
Email
*
Occupation?
Is it OK to leave a message?
Yes
No
Is it OK to use texting for appointment scheduling/confirmations?
Yes
No
Marital Status:
Married
Divorced
Single
Widowed
Other
please specify
Household Members/Significant Others
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Emergency Contact
First
Last
Relationship
Phone
Where did you hear about Halcyon Hospice's Grief Counseling Services?
Information about the Child/Teen
Child's/Teen's Name
First
Last
Date of Birth
MM slash DD slash YYYY
Age
Child's/Teen's School
Grade Level
How would you describe your child’s personality (please check all that apply)?
Quiet, reserved
Slow to warm up to people
Leadership qualities
Talkative
Worries
Night owl
Active
Easy going
Tires easily
Calm
Likes group activities
Angry
Sensitive
Likes one-on-one
Sad
Holds in emotions
Easily frustrated
Information about the Deceased
Name of Deceased
First
Last
Child's/Teen's Relationship to Deceased
Date of Death
MM slash DD slash YYYY
Age at Death
Place of Death
Cause of Death
Does your child/teen know the cause of death?
Yes
No
Was the child/teen present at the time of death?
Yes
No
Child’s/Teen's response at time of death
Can you describe the relationship your child/teen had with the person who died?
Did your child/teen attend a memorial and/or funeral?
Yes
No
What was their reaction?
Was the person who died a hospice patient?
Yes
No
Please give the name of the hospice.
Child’s/Teen's Health & Personal History
(please check all that apply and briefly explain in the space provided).
Does your child/teen have any health issues or concerns?
Yes
No
Please describe:
Does your child/teen have any allergies?
Yes
No
Please describe:
Does your child/teen have any current and/or previous mental health issues or learning challenges?
Yes
No
Please describe:
Has your child/teen been in counseling before?
Yes
No
Is your child/teen currently receiving counseling services from another provider?
Yes
No
Therapist Name
Therapist Phone
Please explain:
Is your child/teen currently taking any medications?
Yes
No
Please list type(s) and reason:
Does your teen have any current and/or previous issues with substance abuse?
Alcohol
Prescription drugs
Recreational drugs
Does your teen have any current and/or previous issues with substance abuse (other)?
Other
please specify
What additional stressors are currently in your family’s or child’s/teen's life?
Financial
Legal Family/Relationships
Death of family member
Moved schools
Moved classrooms
Change in child care
Moved homes
Death of a pet
Illness
Change in job of parent(s)
Change within home (i.e new sibling, others living in home)
Change in primary living situation
What additional stressors are currently in your family’s or child’s/teen's life (other)?
Other
please specify
How many hours of sleep does your child/teen average each night?
Has your child/teen experienced any changes in appetite?
Increase
Decrease
Weight loss
Weight gain
Has your child/teen recently experienced and changes in energy level?
Increase
Decrease
Has your child/teen experienced any other recent losses or significant change?
Yes
No
Please describe:
Who or what is your child’s/teen's primary source of emotional support?
Family
Friends
Teacher/school counselor
Church/Faith Community
Who or what is your child’s/teen's primary source of emotional support (other)?
Other
please specify
What concerns do you have regarding your child/teen (please check all that apply)?
Multiple losses or stressors
Anger, guilt, anxiety, fear, sadness, worries
Difficulty coping
Need additional support
Relationship concerns/issues
Grief support and education for parent/guardian
What concerns do you have regarding your child/teen (please check all that apply) (other)?
Other
please specify
What do you hope to gain from counseling (please check all that apply)?
Information about the grief process
Increase existing support system
Expression of Grief
Develop coping tools/resources for self-care
Increased confidence in coping with emotions
What do you hope to gain from counseling (please check all that apply) (other)?
Other
please specify
As your counselor, is there anything else you would like me to know about your child or family?
Consent
Consent
I consent to allow Halcyon Hospice to collect the information on this form.
*Information included on this form is protected by the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and will remain confidential between the applicant and group facilitators and will not be shared with the group without specific permission.
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