School Group Form 25-26

Please enter parent/caregiver name in the first box below.
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Questions about the person who died:

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We are pleased that Jessica’s House will be providing grief support for our students on a limited basis. The primary purpose of the support is to help your child cope with the death of a friend or family member which may be impacting your child’s school performance. Your child will have the opportunity to participate in a Peer Support Group on a bi-weekly basis with a trained facilitator. As a part of the group we may ask for each child to participate in a ten-question entry and exit survey. Gathering this information allows Jessica’s House to improve the peer support groups to meet the needs of participants and share findings with our stakeholders.

Jessica’s House will maintain the confidentiality of the information your child shares with the facilitator with the following exception. As mandated reporters in the State of California, we are required by law to report any suspected child abuse, neglect, or imminent danger of harm to self or others to Child Protective Services or the appropriate law enforcement agency. Because parental or legal guardian permission is needed for your child to receive this service, I, the undersigned, authorize Jessica’s House to provide Grief/Loss support for my child by checking yes or no below and submitting this form.