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.