The Hope and Healing Place · Generations enrollment form

Primary Family Contact

This portion of the form should be filled out by the responsible party interested in the Generations Program. There are additional fields below for other adults and minors that will be attending in your family grouping.

Your Name

*

First Name

Last Name

Your Relation to Deceased

*

Email

*

Verify Email

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Primary Phone Number

*

Secondary Phone Number

Communication

*

Please select the best way for us to communicate with you.

Call

Text

Email

Social Media

Please select Social Media platforms that you utilize.

Facebook

Twitter

Instagram

None

Employer

Who referred you to The Hope & Healing Place?

Are you or anyone in your family currently (or in the last year) receiving counseling?

Yes

No

Who and for what reason?

Additional or Other Adult Family Members Attending Program

Generations is a program that is meant for the varying generations of the family (Parents, Grandparents, Aunts, Uncles, and so on) to accompany school-aged children (K-12). In this section please list each adult (other than yourself) that will be in attendance.

Will additional adults be accompanying you in this program? You may enter up to four.

Additional Adult #1

*

First Name

Last Name

Relation to Deceased

*

Click here to enter another adult.

Additional Adult #2

First Name

Last Name

Relation to Deceased

*

Click here to enter another adult.

Additional Adult #3

*

First Name

Last Name

Relation to Deceased

*

Click here to enter another adult.

Additional Adult #4

*

First Name

Last Name

Relation to Deceased

*

School-Aged Children

K-12th Grade

Will additional school-age children be accompanying you in this program? You may enter up to 5.

*

Yes

Child #1

*

First Name

Last Name

Date of Birth

*

(mm/dd/yyyy)

Relation to Deceased

*

School

*

Grade

*

Does this child need any accommodations or modifications due to any disability? (Answer: No or Yes, with explanation).

*

Do you want to enter an additional child?

Child #2

*

First Name

Last Name

Date of Birth

*

(mm/dd/yyyy)

Relation to Deceased

*

School

*

Grade

*

Does this child need any accommodations or modifications due to any disability? (Answer: No or Yes, with explanation).

*

Do you want to enter an additional child?

Child #3

*

First Name

Last Name

Date of Birth

*

(mm/dd/yyyy)

Relation to Deceased

*

School

*

Grade

*

Does this child need any accommodations or modifications due to any disability? (Answer: No or Yes, with explanation).

*

Do you want to enter an additional child?

Child #4

*

First Name

Last Name

Date of Birth

*

(mm/dd/yyyy)

Relation to Deceased

*

School

*

Grade

*

Does this child need any accommodations or modifications due to any disability? (Answer: No or Yes, with explanation).

*

Do you want to enter an additional child?

Child #5

*

First Name

Last Name

Date of Birth

*

(mm/dd/yyyy)

Relation to Deceased

*

School

*

Grade

*

Does this child need any accommodations or modifications due to any disability? (Answer: No or Yes, with explanation).

*

Significant losses your family has experienced:

Most recent loss and your reason for contacting HHP:

Deceased's Name

*

First Name

Last Name

Birthday

*

(mm/dd/yyyy)

Date of Death

*

(mm/dd/yyyy)

Cause of death

*

Other information about the cause of death

If death was by suicide, do your children know this?

*

Yes

No

Death not by suicide

Additional Death

Yes

Additional Deceased's Name

*

First Name

Last Name

Birthday

*

(mm/dd/yyyy)

Date of Death

*

(mm/dd/yyyy)

Cause of death

*

Other information about the cause of death

If death was by suicide, do your children know this?

*

Yes

No

Death not by suicide

Additional Death

Yes

Additional Deceased's Name

*

First Name

Last Name

Birthday

*

(mm/dd/yyyy)

Date of Death

*

(mm/dd/yyyy)

Cause of death

*

Other information about the cause of death

If death was by suicide, do your children know this?

*

Yes

No

Death not by suicde

Other Additional Losses Your Family Has Experienced

Additional recent losses

Check all that apply

Death of pet

Divorce/Separation

Loss of home/moving

Change in schools

Separation of siblings

Loss of income/employment

Who is your most immediate concern and what are the circumstances around your concern?

*

Is there anything else you would like the facilitator to know about you or other family members?

*

Additional Information:

Other family members or notes for staff

Thank you for enrolling into our program. A member of the HHP Team will get back to you within 2-3 business days.

Electronic Signature

*

Full Name

Date

*

(mm/dd/yyyy)