Grief Group Registration Form
Art in Motion will soon begin the support group for our students who have experienced grief and/or loss due to the death of a loved one, separation of family member(s), divorce, foster care and/or incarceration. As we continue to support the WHOLE student, we believe here at AIM that allowing students to appropriately express their thoughts and feelings of loss in a monitored setting by a trained professional encourages the students’ growth and healing in order to promote success academically, creatively, socially and emotionally.

If your pre-teen/teen has experienced a loss such as those mentioned above, please feel free to review what we have to offer in terms of our grief and loss group. Please complete the online registration form no later than January 29, 2021. Thank you for your cooperation and we look forward to servicing your pre-teen/teen here at Art In Motion.

Please note: Mrs. Lee, Art In Motion’s School Social Worker will be the facilitator of this group. This group will take place via zoom ONCE a week from 2-2:30p for six consecutive weeks. There will be an additional week included after the sixth week for a small celebration for the students (via zoom). This form is due no later than Friday, January 29, 2021. Forms will NOT be accepted after this date. This is to maintain the integrity of the group so that students may begin group work together and end together. If your pre-teen/teen misses a day of school for which the group takes place, make up work is not a requirement but you are at liberty to request the activity for that session be sent via email. Thank you and I look forward to working with your pre-teen/teen through this process. If you have any questions or concerns, please email me at alee@distinctiveschools.org.
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電子郵件 *
Student First Name *
Student Last Name *
Student Grade Level *
Student Age *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Parent/Guardian Phone Number *
Parent/Guardian Address *
Emergency Contact Name *
In case of emergency, if parent/guardian is not reachable, list someone you would like us to contact
Emergency Contact Phone Number *
In case of emergency, if parent/guardian is not reachable, list phone number of person listed above.
Specify the loss (i.e. person who died and/or if there is a separation due to divorce, foster care, incarceration, etc) *
Date of Death/Separation   *
Sibling(s) name(s)  and age(s) *
What other significant changes have taken place in your pre-teen/teen’s life during the past two years?   *
It is imperative that a pre-teen/teen who is exhibiting behaviors which may be harmful to him or herself or others be seen by a mental health professional before joining a grief group. The therapist will help determine when it would be appropriate for the pre-teen/teen to attend such a group. At that point, it may be advisable for the pre-teen/teen to attend the group while continuing to meet with the therapist. Does your pre-teen/teen exhibit any such behaviors? *
Please answer yes or no and comment below.
Are there other concerns for your pre-teen/teen you wish to comment on?
Please answer yes or no and comment below.
Please enter your full name below as an electronic signature that you have read and agreed to the terms and conditions of AIM Studio After School Programming. *
Please type your name below as a digital signature to acknowledge the expectations and participation in The Student Grief Group and the in the Virtual Peace Room at Art In Motion. I give permission for my student to participate. *
The Peace Room ●  Arrive on time.​ The Peace Room is designed to be utilized for specific purposes at specific times so please be respectful of the schedule.●  An adult MUST be present in The Peace Room with a student(s) at ALL times.​ This is to ensure the safety of all staff and students.●  Be sure to sign in upon entering The Peace Room (both staff and students). ​We want to continue to be accountable of who enters and exits the room and be responsible for the space.●  Place cell phones/laptops and all electronics in tech bin prior to starting a session (either on silent or off).​ The Peace Room is a “no-tech” zone so please be sure to step outside of the room if you need to make or answer a call or text.●  Be conscious of scents and odors. ​This space is designed to be calming, relaxing and to awaken the scenes so please be mindful of perfumes, colognes and personal hygiene.●  Please keep noise and voices to a minimum while entering, occupying and exiting The Peace Room.​ Classes as well as meetings will still be in session the majority of the time the Peace Room is being utilized, so please be conscious of the volume.●  Food and drinks are not allowed  in the Peace Room.​ ●  The Peace Room is meant to develop a *“CREATIVE” culture at AIM. *Community *R​esilience *E​xcellence *A​ccountability *T​enacity *I​dentity*V​oice E​mpathy
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