Support Options

Cause/Circumstance Surrounding the Death (Please note that this question is asked to determine which support group and/or Bereavement Care Specialist would be the most appropriate to meet your needs).

Please indicate which time your family prefers to attend on May 4. (Please note that changes to this time may only be made by emailing griefsupport@childrens.com before April 23).

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.

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 2025 Remembrance Gathering. This permission may be revoked at any time by calling 214-456-3555 or emailing griefsupport@childrens.com

Family Shirt Sizes

Please check here if you prefer not to receive shirts.

Consent for Bereavement Support Services

By signing this box, I am indicating that I have read and understood this consent, and I am voluntarily consenting to receive bereavement support services provided by Children's Health. 

Bereavement Support Services: Children's Health offers bereavement support services, including grief support as part of the normal grief support process. These support services are offered to individuals or families who may be grieving from a loss. The grief support services may be offered in different settings, including individual sessions and support groups.  These services do not include any behavioral or mental health therapy or treatment.

The bereavement support services may be conducted through interactive audio, video or other electronic media, and there are both risks and benefits to receiving services through one of these electronic media.  Use of electronic media may be limited or unavailable at times because of technological or equipment failures, incomplete or inaccurate data or distortion of images or other information from electronic transmissions. I acknowledge that the Children's Health and its Bereavement Care staff cannot be held liable for advice, recommendations and / or decisions   based on factors not within their control, such as incomplete or inaccurate data provided by you or distortions of images resulting from electronic transmission. I understand precautions are taken to protect the confidentiality of the participant's confidential information from unauthorized disclosure; however, I understand and acknowledge that the security of electronic transmission of data, video images, and audio information cannot be guaranteed and confidentiality may be compromised by illegal or improper tampering.

I consent for me to receive bereavement support services provided by Children's Health via in-person sessions or through interactive audio, video, or other electronic media, and understand the nature and extent of the potential risks involved.  I understand that the bereavement support services may include discussions of family and work issues, and my health in individual sessions and support groups.  The level of participation in receiving the bereavement support services will be determined by me. I understand that I may stop participation at any time by notifying in writing the Bereavement Care staff. I acknowledge that the Bereavement Care staff have not offered any guarantee and are not responsible for any outcomes from the bereavement support services for me.

As a condition of receiving bereavement support services, I understand and agree that I am not allowed or permitted to make any type of recording (including audio and/or video) of the bereavement support services.

Confidentiality: I understand that all information obtained while participating in bereavement support services is considered confidential, including any information that I may receive in participating in support groups. I understand and agree that I am required to keep the information obtained through our participation in support groups or other settings as confidential and shall not discuss or share, in any way, this confidential information 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 any 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.

Release of Liability: In consideration of my 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, costs and expenses caused or resulting from any injury, of any type, that I may have while participating and/or receiving and/or otherwise connected to bereavement support services.

This consent is valid for one year from the date signed unless I revoke it sooner. To revoke the consent, the request needs to be made in writing and sent by email to griefsupport@childrens.com or by mail to the following address: Children's Health, Attention: Manager of Bereavement Care Program,  1935 Medical District Dr., Dallas, TX 75235.

I have read and understood this Consent and have had a chance for my questions to be answered. I voluntarily provide my consent.