Date Rec’d: ______________
ID:____________________
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 Guardian
Family 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
Female
Transgender
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
Do they receive special services (i.e., tutoring, etc.)? Yes
Unknown
No
Unknown
If yes, describe: ____________________________________________________________________________________
Roberta’s House, Inc.
rev 1/2014
Does the child/teen have any learning disabilities or impairments? (please circle all that apply)
Cognitive Speech
Emotional None
Language (reading/writing)
Mathematical
Visual
Behavioral
Unknown
Other: ___________________________________________________
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
Circle all that apply: Asthma Diabetes
Other: _______________________________________
Seizures
Allergies
Has the child/teen been diagnosed with a psychiatric disorder? Yes
Unknown
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
Is child/teen still receiving professional counseling? Yes
School-based
No
Residential/Inpatient
Unknown
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
What services does the child/teen need now? Counseling/Therapy
Behavioral Support
Family Support
After-School Care
Medication/Psychiatric Consult
Other: ______________________________________
Is this the first direct experience the child/teen has had with death? Yes
If no, please list:
Name
________________________________________
________________________________________
________________________________________
No
No
Unknown
Relationship to child/teen
___________________________________
___________________________________
___________________________________
Roberta’s House, Inc.
Date of death
___________
___________
___________
rev 1/2014
Are there any other changes/stresses in child/teen’s life? (please circle all that apply)
Personal illness
Illness of a loved one/friend
Relocation to a new house or community
Friends moving away
Accidents (e.g.,car, etc.) Witness to a crime
Theft or loss
None Unknown
Friend/Love one incarcerated
Divorce or separation
Parents/caregivers changing jobs
Victim of a crime
Legal involvement
Death of a pet
Fire
Other: ______________________________________________________________
Group information
Is the child/teen interested in group support? Yes
Unknown
No
Court Ordered
Persuaded (e.g., by parents/caregivers)
Other: ________________________________________________________________________________
How has the child/teen responded to groups in the past? (Check all that apply): Enjoyed groups
Participated in group
Refused to participate
Never in a group
Have they ever been asked to leave a group permanently? Yes
Unknown
No
Disliked groups
Other: ______________________
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 family
Referral for therapy
Education about grief
Referral to community resources
Treatment for child/teen’s difficulties
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