Family/Child Application

Family/Child Application

Date: ______

Name of Parent/Legal Guardian: ______

Address: ______Apt: ______

City: ______State: ______Zip: ______

Home Phone: ______Cell Phone: ______Email: ______

Place of Employment: ______

Work Phone: ______Work Email: ______

If different than above

Name of person filling out this form: ______

Parent/Legal GuardianFamily Member Case Worker

If family, your relationship to the child/teen: ______

If Case Worker, how long have you worked with or know the child/teen? ______

Agency Name:______

Referred by: ______

Your Address: ______Apt:______

City: ______State: ______Zip: ______

Home Phone: ______Cell Phone: ______Email:______

Work Phone:______Work Email: ______

Individual Child/Teen Information

Please complete for each child/teen

Child/Teen’s full name: ______Age:______

Gender: Male FemaleTransgender

Address ______

City______State______Zip ______

Name child/teen wants to be called: ______Date of Birth: ______

School Information

Did the child/teen drop out of school? Yes No Unknown

If yes, when? ______Why? ______

Name of school: ______Grade: ______

Is child/teen in regular education classes?Yes No Unknown

Do they receive special services (i.e., tutoring, etc.)? Yes No Unknown

If yes, describe:______

Does the child/teen have any learning disabilities or impairments?(please circle all that apply)

CognitiveSpeechLanguage (reading/writing)Mathematical Visual Behavioral

EmotionalNone UnknownOther: ______

Will they need any assistance with reading or writing on their grade level? Yes No Unknown

Medical Information

Does the child/teen have any chronic medical conditions? Yes No Unknown

Circle all that apply: Asthma Diabetes Seizures Allergies Other: ______

Has the child/teen been diagnosed with a psychiatric disorder? Yes No Unknown If yes, when:______

Please describe: ______

Is child/teen taking any medications? Yes No Unknown If yes, list: ______

______

Has child/teen received any services or professional counseling by:Therapist Clergy City/State Agency Other:______If so, start date: ______and end date: ______

Was the service or professional counseling: Outpatient School-based Residential/Inpatient Unknown

Is child/teen still receiving professional counseling? Yes No Unknown

Information about the deceased person(s):Please list only those deaths that have impacted the child/family directly.

First Loss/ Name: ______

Age at Death: ______Date of Death: ______Cause of Death: ______

Relationship to the child/teen: ______

Did the child/teen witness the death? Yes No Did the child/teen discover the body of the deceased? Yes No

Who told the child/teen about the death? ______

Did the child/teen attend the funeral? Yes No Did the child/teen view the deceased? Yes No

Second Loss/Name: ______

Age at Death: ______Date of Death: ______Cause of Death: ______

Relationship to the child/teen: ______

Did the child/teen witness the death? Yes No Did the child/teen discover the body of the deceased? Yes No

Who told the child/teen about the death? ______

Did the child/teen attend the funeral? Yes No Did the child/teen view the deceased? Yes No

What services does the child/teen need now? Counseling/Therapy Medication/Psychiatric Consult

Behavioral Support Family Support After-School Care Other: ______

Is this the first direct experience the child/teen has had with death? Yes NoUnknown

If no, please list:

NameRelationship to child/teen Date of death

______

______

______

Are there any other changes/stresses in child/teen’s life? (please circle all that apply)

Personal illness Illness of a loved one/friendFriend/Love one incarcerated Divorce or separation

Relocation to a new house or communityFriends moving awayParents/caregivers changing jobs

Accidents (e.g.,car, etc.) Witness to a crime Victim of a crime Legal involvement Death of a pet Fire

Theft or loss None Unknown Other: ______

Group information

Is the child/teen interested in group support? Yes No Court Ordered Persuaded (e.g., by parents/caregivers) Unknown Other: ______

How has the child/teen responded to groups in the past? (Check all that apply): Enjoyed groups Disliked groups Participated in group Refused to participate Never in a group Unknown Other: ______

Have they ever been asked to leave a group permanently? Yes No If yes, please explain: ______

Member of the support system that will attend sessions with this child/teen:

Name: ______Phone: ______

Relationship to child/teen: ______Email: ______

Does child/teen require transportation to attend sessions? Yes No

Please describe any special circumstances or provide additional information you feel is important: ______

______

Goals

What do you expect to gain from the bereavement program at Roberta’s House? (Please circle all that apply)

Support for the child/teen or familyEducation about grief Treatment for child/teen’s difficulties

Referral for therapy Referral to community resources Unknown Nothing

Other: ______

Please note anything else we should know about child/teen, the deceased, or the circumstances of their death? ______

______

Please mail application ATTN: Family Program:

Roberta's House at 1900 N. Broadway, Suite 101, Baltimore, MD 21213

or fax to 410-235-6636

Roberta’s House, Inc. rev 1/2014