Family Information Form

Your name:

Your relationship to the child(ren):

Address:

City:

State:

Zip Code:

Email Address:

Phone Number:

May we contact you during work hours?
YesNo

Employer:

Occupation:

If not the child(ren)'s parent/legal guardian, who is?
Name:

Address:

Phone Number:

List name of person(s) who will be bringing the child(ren) to FMN, the relationship to the child(ren) and phone number(s):

Please list the children who will be attending, their birth date, age, and gender:

Who was the person that died?
Name:

Birth Date:

Date of Death:

Causes and circumstances of death:

Where did the death occur?

She/he was my:

She/he was the child(ren)'s:

Have the children been told everything about the death?
YesNo

What have they not been told?

Were the children involved in the burial, funeral, or memorial service?
YesNo

What other deaths or losses has your family experienced?

What grief reactions or changes in behavior since the death occurred have you concerned?

What other services to help with coping with grief have the children received?

Are there spiritual/religious practices important in the children’s lives that you would like us to be aware of?

How did you hear about Forget Me Not?

Is there anything you would like to share that we have not talked about?