Caleb's Kids Support Group Registration
Date(s): 1st and 3rd Wednesday of Each Month
Time: 6:00pm - 7:00pm
Location:

Caleb's Kids (located inside of the Durfee Innovation Society Building)
2470 Collingwood St.
Suite 206
Detroit, Michigan 48206

Questions: Contact Timmie Roberts at 313-437-7285 or troberts@calebskids.org

**All information is confidential and will not be shared outside of assigned Caleb's Kids staff**

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Participant First Name *
Participant Last Name *
Participant Phone Number *
Participant Email *
Participant Home Address 
(please include city, state, zip code)
 *
Participant Date of Birth *
MM
/
DD
/
YYYY
Participant Gender *
Participant Ethnicity *
Have you ever joined a suicide support group before? *
Required
If yes, please describe what you gained from previous support groups.
What do you hope to gain from the weekly sessions? *
Have you had thoughts of suicide or homicide in the last 72 hours? *
If yes, please dial 988 immediately.  
Emergency Contact Name *
Emergency Contact Phone *
Relationship to Emergency Contact *
Emergency Contact Address *
Consent and Release
The purpose of the support group is to help you with concerns related to your loss and how to help you use self-help tools to heal from grief. You may be here because you wanted to talk to receive assistance from with these self-identified concerns. The group facilitator will provide support, education and tools to help you as a plan for you to improve these problems. It is important that you feel comfortable talking to me about the issues that are bothering you.
I understand that this is a support group and is not therapy or intended to be a substitution for therapy or any other clinical mental health treatment program. *
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