Project Hope Intake Form

Student Intake Information

All information submitted on this form is considered confidential and is not shared outside of the clinical team. Instructions: Please complete a section for each student you have identified for this group. The following information MUST be included: 1. Student name. 2. Student age and grade. 3. Date that student was invited to/informed of group. 4. Loss information (include name of deceased, date of death, relationship to student, and circumstances). 5. Current living situation.