Registration Form for Coaching Sessions

For Parents with Children Who Are Grieving

Please fill out the form below and we will be in contact with you with the next steps in this process. 

Name

Email

Phone

Address

City

Zip Code

Relationship to Student: Parent Step Parent Legal Guardian

Name of Student:

Current Grade Level:

Name of Deceased:

Relationship to Student:

Relationship to You:

When did the death occur?

What was the cause of death?

Where did the person die?

Was the child present at time of death?

Yes

No

Was there a service (funeral/memorial/celebration of life)?

Yes

No

Did the student attend?

Yes

No

When someone we love dies, it affects our lives emotionally, physically, mentally, socially, and spiritually. How does your student’s grief continue to impact any of these areas?

How does the student currently express his or her grief feelings that concern you or where you have noticed a change? (check all that apply)

Angry outbursts

Fighting with siblings/others

Exaggerated emotions

Changes in eating or sleeping patterns

Regression to an earlier developmental stage

Bullying behavior

Physical complaints

Changes in sleeping or eating

Indifference toward schoolwork

Easily distracted/difficulty concentrating

A change in class performance or not wanting to go to school

Overwhelmed by intense emotions (anger, grief, fear, sadness, irritability, and/or moodiness)

Blaming themselves for the death

Having questions or concerns about death, dying, mortality

Withdrawal or isolation

Is your student displaying aggressive or risky behavior (please specify)?

What do you feel you need most from Coaching?

Thank you for contacting us.
We will get back to you as soon as possible

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