Join the Bereavement Care Email List
Register to receive an individual support session for yourself or for your family
Register for Support Groups
Register for Camp Sol (REGISTRATION CLOSED UNTIL 8/15/24)
Fill out consent form (only needed if already registered for an event)
Join the Bereavement Care Email List
Register to receive an individual support session for yourself or for your family
Register for Support Groups
Register for Camp Sol (REGISTRATION CLOSED UNTIL 8/15/24)
Fill out consent form (only needed if already registered for an event)
Registration for Camp Sol is currently closed and will reopen on August 15. The next Camp Sol retreat will be held October 4-6, 2024, and it is open to families who have experienced the death of a child and have additional children 18 years or younger. Please join the Bereavement Care Email List to receive information about upcoming support groups and other Bereavement Care events.
Bereavement Support Email List
Family Support Groups Children's Health Specialty Center-Dallas September 9, 16, and 23 6-8 pm
Family support groups are appropriate for parents and their children under the age of 18 who have experienced the death of a child. To participate in the drop-in monthly virtual support group, please choose the option "Join the Bereavement Care Email List", and a Zoom link will be sent to your email the day before the next scheduled group.
For the 3 week session of virtual groups for mothers or fathers, please register at https://redcap.link/qprzwdf6.
Registration for the Remembrance Gathering is currently closed. Please choose "Join the Bereavement Care email list" to receive an email about upcoming events.
Registration for Individual, Couple, or Family Grief Support Sessions Once this form is completed, you will be contacted by a Bereavement Staff Member within 72 hours to schedule a session. What is your first name?
* must provide value
What is your last name?
* must provide value
What is your relationship to the child who has died?
Mother Father Guardian Other
What is your race/ethnicity?
What is your language preference?
* must provide value
English Spanish Other
If other, please specify:
Phone number
* must provide value
Preferred Email Address
* must provide value
Additional Email Address (optional)
Mailing Address
* must provide value
Emergency Contact
* must provide value
Emergency Contact Phone Number
* must provide value
Please specify any relevant medical, developmental, or mental health needs.
In person
Virtual
Will another caregiver be attending?
* must provide value
Yes
No
Mother Father Guardian Other
Caregiver 2 Race/Ethnicity
Caregiver 2 Language Preference
* must provide value
English Spanish Other
If other, please specify:
Caregiver 2 Relevant medical, developmental, or mental health needs
Caregiver 2 Support Group Options
In person
Virtual
Have you experienced the death of a child?
* must provide value
Yes
No
I am joining this list as the following:
Grieving family member or friend Professional Community organization/school Student Other
Please indicate if other:
Child's First Name
* must provide value
Child's Last Name
* must provide value
Child's Preferred First Name (If Different)
Child's Preferred Last Name (If Different)
Date of Birth
* must provide value
Today M-D-Y
Date of Death
* must provide value
Today M-D-Y
Cause/Circumstance Surrounding the Death
* must provide value
Was this an extended illness?
Yes
No
Did your child receive any treatment at Children's Health (not required for grief services)?
* must provide value
Yes
No
Do you have an additional child who died?
* must provide value
Yes
No
Child's First Name
* must provide value
Child's Last Name
* must provide value
Child's Preferred First Name (If Different)
Child's Preferred Last Name (If Different)
Date of Birth
* must provide value
Today M-D-Y
Date of Death
* must provide value
Cause/Circumstance Surrounding the Death
Was this an extended illness?
Yes
No
Did your child receive any treatment at Children's Health (not required for grief services)?
Yes
No
Does your family include surviving siblings under the age of 18?
* must provide value
Yes
No
Will any siblings under the age of 18 be participating? (Please note that sibling participation is required for Family Support Groups in September and Camp Sol).
Yes
No
Sibling 1 First Name
* must provide value
Sibling 1 Last Name
* must provide value
Sibling 1 Birthday
* must provide value
Today M-D-Y
Sibling 1 Relevant medical, developmental, or mental health needs
Is there another sibling attending?
* must provide value
Yes
No
Today M-D-Y
Sibling 2 Relevant medical, developmental, or mental health needs
Is there another sibling attending?
* must provide value
Yes
No
Today M-D-Y
Sibling 3 Relevant medical, developmental, or mental health needs
Is there another sibling attending?
* must provide value
Yes
No
Today M-D-Y
Sibling 4 Relevant medical, developmental, or mental health needs
Is there another sibling attending?
* must provide value
Yes
No
Today M-D-Y
Sibling 5 Relevant medical, developmental, or mental health needs
Is there another sibling attending?
* must provide value
Yes
No
Today M-D-Y
Sibling 6 Relevant medical, developmental, or mental health needs
Is there another sibling attending?
* must provide value
Yes
No
Today M-D-Y
Sibling 7 Relevant medical, developmental, or mental health needs
Will your family be attending in person, livestream, or both?
In-person
Livestream
Both
Participant 1 name (Please include your name if you are planning to attend): Is the participant an adult or a child under the age of 18? Participant 2 name: Is the participant an adult or a child under the age of 18? Participant 3 name: Is the participant an adult or a child under the age of 18? Participant 4 name: Is the participant an adult or a child under the age of 18? Participant 5 name: Is the participant an adult or a child under the age of 18? Participant 6 name: Is the participant an adult or a child under the age of 18?
Is this participant a child or an adult?
Adult
Child (under 18 years)
Adult
Child (under 18 years)
Is this participant a child or an adult?
Adult
Child (under 18 years)
Adult
Child (under 18 years)
Is this participant a child or an adult?
Adult
Child (under 18 years)
Adult
Child (under 18 years)
Is this participant a child or an adult?
Adult
Child (under 18 years)
Adult
Child (under 18 years)
Is this participant a child or an adult?
Adult
Child (under 18 years)
Adult
Child (under 18 years)
Is this participant a child or an adult?
Adult
Child (under 18 years)
Adult
Child (under 18 years)
How many adult family members will watch the livestream?
How many child family members (under the age of 18) will be watching the livestream?
As a part of the Remembrance Gathering, we would like to put together a slideshow of pictures representing the children we have come to honor. These could include pictures of your child or other special memories. Please limit to no more than 5 pictures.
* must provide value
I would like to upload my pictures now.
I would prefer to email up to 5 pictures to griefsupport@childrens.com before April 1, 2024.
I prefer to have only my child's name and no pictures in the slideshow.
I would like to upload my pictures now.
I would prefer to email up to 5 pictures to griefsupport@childrens.com before April 1, 2024.
I prefer to have only my child's name and no pictures in the slideshow.
Photo: Photo: Photo: Photo: Photo:
Photo/Reading of Name Permission Statement
By providing photos or other special memories for this event, I am permitting the Children's Health Bereavement Care Program to read aloud the name of my child and publicly show the images to both the in-person and virtual attendees of the 2024 Remembrance Gathering. This permission may be revoked at any time by calling 214-456-3555 or emailing griefsupport@childrens.com
* must provide value
Grief Support Information
What grief support have you or your family received (e.g. Camp Sol, Support Groups, counseling, etc.)?
Family Shirt Sizes
Please check here if you prefer not to receive shirts.
No shirts needed
Please list the number of shirts needed in each size.
2T: Adult S: 3T: Adult M: Youth XS: Adult L: Youth S: Adult XL: Youth M: Adult 2XL: Youth L: Adult 3XL: Youth XL:
If you are registering more than one person, please describe the type of session you prefer (i.e. group session for family or couple, separate session for each family member, separate sessions for parent and children, etc.).
Consent for Bereavement Support Services By signing this box, I consent for myself and if applicable, for my minor children listed on this form, to receive bereavement support services provided by Children's Health. I understand that the bereavement support services may include discussions of family and work issues, the health of me and my children, and may be offered in different settings, including individual sessions and support groups. My family and I determine the level of participation in receiving these support services and may stop participation at any time by notifying the Bereavement Care staff. The Bereavement Care staff, including any group therapy facilitators, provide grief support for normal grief processing but do not provide any behavior or mental health therapy or treatment. I acknowledge that the Bereavement Care staff have not offered any guarantee and are not responsible for the bereavement outcomes of my children and myself. The bereavement support services may be conducted through interactive audio, video or other electronic media, which may be less secure than in-person support. I consent to receive bereavement services through these types of electronic media and understand the nature and extent of the potential risks involved. As a condition of receiving bereavement support services, I understand and agree that no one in my family is allowed to make any type of recording (including audio and/or video) of the support services. Confidentiality: I understand that all information obtained while participating in bereavement support services is to be considered confidential, including any information that I or my children may receive in support groups. I understand and agree that my children and I are required to keep the information confidential and shall not discuss or share this confidential information in any way with anyone else. I understand the Bereavement Care staff are required by law to notify appropriate authorities of any information of abuse, neglect, domestic violence, threat of harm, and communicable diseases. Text / Voice / Automated Messaging: I authorize Children's Health to send communications by text message, voice and automated calls to the cell phone number I provide. I acknowledge that message and standard data rates and fees will apply, message frequency rates may vary, full security is not guaranteed over telephone networks, and I will need to protect my phone with a password or PIN to prevent unauthorized access. I understand that text and automated messaging may not be used by me to notify Children's Health of the Patient's health care needs. Children's Health Mobile Messaging privacy policy and SMS terms of service are available at https://www.childrens.com/footer/policies-procedures. Text HELP to 77444 for mobile messaging assistance, or text STOP to 77444 to opt out of Children's Health Mobile Messaging. Release of Liability: In consideration of my family's receipt of bereavement support services, I agree to release and hold harmless Children's Health and its affiliated entities against any and all liabilities, claims, damages, losses, and costs caused or resulting from any injury, whatever type, that any family member may have while participating and/or receiving and/or otherwise connected to bereavement support services.
* must provide value
If a second adult in your family is registering, please have that adult sign here to indicate agreement with the consent above. If that person is not available at this time, please have them go to www.childrens.com/griefsupportform and choose the option "Fill out consent form" to sign the required form.
If there were something that we should know to better serve you or your family, what would it be?
Exención de campamento-Español
By signing in this box, I am agreeing to the waiver above on behalf of myself and my family.
* must provide value
This form was entered by:
Please do not click submit on this form. Registration is currently closed and only a blank form is sent if you submit at this time. Thank you!