302 c flanagan handout2
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This document is an information form for teens attending a monthly Teen Night activity. It requests the teen's name, contact information, age, birthdate, details about previous support group attendance, information about a deceased family member or friend including their name, relationship to the teen, date and cause of death, how the teen's life has been impacted, and what the teen is looking forward to at the event. The form must be returned before attending Teen Night.
302 c flanagan handout2
- 1. Teen Night – Information Form Thank you for filling out this short background form to help us plan our monthly Teen Night activities. As always, all information that you share will be kept confidential. This form must be returned via fax (502-4564) or email (kgalvin@tedebearhollow.org) before you attend! Teen’s Name: _________________________________________________ Today’s Date: ______________ Teen’s Email Address: _________________________________________________________________________ Parent’s Email Address: _______________________________________________________________________ Home #: __________________ Parent Cell #: __________________ Teen’s Cell #: __________________ Teen’s Age: _______ Teen’s Birthdate: __________________ What TEBH support groups have you attended? When? ____________________________________________ ___________________________________________________________________________________________ Name of the Deceased: ________________________________________________________________________ Relationship to You: __________________________ When did they die? ___________________________ (Parent, Sibling, Spouse/Partner, Child, Grandparent, Friend, etc.) Month Year How did the death occur? ______________________________________________________________________ ___________________________________________________________________________________________ How would you describe your relationship with this person? _________________________________________ ___________________________________________________________________________________________ In what ways has this death impacted your life? ___________________________________________________ ___________________________________________________________________________________________ What brings you support or comfort now? ________________________________________________________ ___________________________________________________________________________________________ What are you most looking forward to at Teen Night? ______________________________________________ ___________________________________________________________________________________________