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Home
About Us
Services
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.