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Teen Night – Information Form
Thank you for filling out this short background form to help us plan our monthly Teen Night activities. As always, all information that you
share will be kept confidential. This form must be returned via fax (502-4564) or email (kgalvin@tedebearhollow.org) before you attend!



Teen’s Name: _________________________________________________                                     Today’s Date: ______________


Teen’s Email Address: _________________________________________________________________________


Parent’s Email Address: _______________________________________________________________________


Home #: __________________                  Parent Cell #: __________________                Teen’s Cell #: __________________


Teen’s Age: _______                    Teen’s Birthdate: __________________


What TEBH support groups have you attended? When? ____________________________________________

___________________________________________________________________________________________




Name of the Deceased: ________________________________________________________________________

Relationship to You: __________________________                        When did they die? ___________________________
(Parent, Sibling, Spouse/Partner, Child, Grandparent, Friend, etc.)                                     Month                  Year


How did the death occur? ______________________________________________________________________

___________________________________________________________________________________________

How would you describe your relationship with this person? _________________________________________

___________________________________________________________________________________________

In what ways has this death impacted your life? ___________________________________________________

___________________________________________________________________________________________

What brings you support or comfort now? ________________________________________________________

___________________________________________________________________________________________

What are you most looking forward to at Teen Night? ______________________________________________

___________________________________________________________________________________________

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302 c flanagan handout2

  • 1. Teen Night – Information Form Thank you for filling out this short background form to help us plan our monthly Teen Night activities. As always, all information that you share will be kept confidential. This form must be returned via fax (502-4564) or email (kgalvin@tedebearhollow.org) before you attend! Teen’s Name: _________________________________________________ Today’s Date: ______________ Teen’s Email Address: _________________________________________________________________________ Parent’s Email Address: _______________________________________________________________________ Home #: __________________ Parent Cell #: __________________ Teen’s Cell #: __________________ Teen’s Age: _______ Teen’s Birthdate: __________________ What TEBH support groups have you attended? When? ____________________________________________ ___________________________________________________________________________________________ Name of the Deceased: ________________________________________________________________________ Relationship to You: __________________________ When did they die? ___________________________ (Parent, Sibling, Spouse/Partner, Child, Grandparent, Friend, etc.) Month Year How did the death occur? ______________________________________________________________________ ___________________________________________________________________________________________ How would you describe your relationship with this person? _________________________________________ ___________________________________________________________________________________________ In what ways has this death impacted your life? ___________________________________________________ ___________________________________________________________________________________________ What brings you support or comfort now? ________________________________________________________ ___________________________________________________________________________________________ What are you most looking forward to at Teen Night? ______________________________________________ ___________________________________________________________________________________________