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Kids’ Haven collects information about our participant families and the death they are grieving. Our work with you and your family is confidential, and all information is private.

All families must complete this form before joining group night. If you prefer to handwrite forms, you may print them out here. When attending your first group night, both the guardian and all participants will also sign the Family Agreement Statement and Privacy Statement. A copy of these statements can be viewed and/or printed here. We will also have paper copies at Group Night.

A member of staff would be happy to assist you in completing these forms. Please email programs@kidshavenlynchburg.org or call 434.845.4072 to set up an appointment.

Contact Information

Your name *

First Name

Last Name

Relationship to the child(ren) who will participate: *

Are you the child(ren)'s legal guardian? *

Yes

Email *

Contact Phone Number

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please list all participating family members: yourself, other adults, teens, and children: *

Please include name, birth date, age and gender for each participant.

Occupation

Employer

Questions about the person that died

Name *

Birthdate *

YYYY

Date of death *

YYYY

Cause of Death: *

The person died at: *

Home

Hospital

Work

Other

The person that died was my

The person that died was the child(ren)s:

Any additional details about the death: *

Has your family experienced other deaths in the last 12 months?

Questions about the child(ren) attending:

Is the child(ren) currently receiving counseling or therapy? *

Yes

Does the child(ren) have a diagnosis that could impact them in a group setting?

Yes

If yes to the question above, please explain.

The children / teens attend school at: *

Other

Emergency Contact Person

First Name

Last Name

Emergency Contact phone number

(###)

###

####

Emergency Contact Relationship to the participant:

How did you hear about Kids' Haven?

Thank you for completing the intake paperwork for Kids’ Haven group night. Your responses will be shared with our Programs Coordinator, who will follow up to schedule your first group.

Kids’ Haven: A Center for Grieving Children is a proud member of the National Alliance for Children’s Grief and a Friend of the Coalition to Support Grieving Students.