JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Students Facing Grief - Family Survey (Beaumont YSC) *To be completed by parent or guardian
Our Youth Service Center has received a grant to provide professional grief support services for our students and families. We need your help! Please complete the following questions (one survey PER CHILD).
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Has your child lost an *important person during March 2020-present? *important person may include but is not limited to a parent, grandparent, relative, sibling, friend, neighbor
*
Yes
No
Before March 2020, has your child EVER lost an important person?
*
Yes
No
If you answered YES to the questions above, please let us know the reason for the loss. This will help us provide groups that will better serve your child's needs.
Accidental death
Long-term illness/Chronic health condition
Short-term illness
COVID-19
Overdose
Suicide
Gun Violence
Other:
If your child has lost an important person, did they receive any following kinds of help or support for grief? (check all that apply)
Individual counseling (1-3 sessions)
Family counseling (3+ sessions)
Small group counseling
Camp Hope (sponsored by Hospice)
Written materials/books about grief
None of the above
Other:
Clear selection
Would be interested in your child participating in professional-led peer support groups held during the day for 10 weeks this fall/winter?
*
Yes
No
Not applicable
If you are interested in more information or would like for your child to participate in this free professional-led peer support group please
list your child's name
.
Your answer
If you are referring a student please list your name and contact phone please.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Fayette County Public Schools.
Report Abuse
Forms
