Pathfinders Group Interest Form

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Thank you for your interest in our six week Pathfinders group for children who have experienced primary death loss. Please complete the following form to share your interest in the group and to help us determine if this group is the right fit for your child. Completion of this form does not guarantee a spot in this therapy group. This information will be used to inform the creation of a group that will support each participant's success in this group.

Please respond to these questions honestly and to the best of your ability. We will review all the responses and respond within two business days. Please reach out to us directly if you have any questions.

Kristin Goodman, kristin@yournextchaptercounseling.com

Emmi Lohrentz, emmi@yournextchaptercounseling.com

Your name (parent/guardian): *

Your phone number: *

Your email: *

Your child's name:

How old is your child? *

Under 8 years old

8 years old

9 years old

10 years old

11 years old

Over 11 years old

Is your child comfortable with participating and socializing in small group games and activities? *

Yes, they are able to participate with ease.

Sometimes. They may be slow to warm up, or need support from an adult to feel comfortable working in small groups.

No, my child prefers to work independently or one-on-one with an adult.

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