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Stepping Stones Enrollment Pre-Evaluation

Building bridges of hope for lowcountry families since 1980

Caregiver Information (parent or guardian)

Name *

First

Last

Bereavement Information

What is the Deceased relationship to Child? *

Date of Death

Type of Death *

Child/Teen Information

Child/Teen Name *

First

Last

Child/Teen makes goals for the future *

Never
Sometimes
Always
Not Sure

Child/Teen speaks openly about their feelings and emotions *

Never
Sometimes
Always
Not Sure

Child/Teen asks questions about the death or deceased *

Never
Sometimes
Always
Not Sure

Child/Teen displays unhealthy coping skills *

Never
Sometimes
Always
Not Sure

Child/Teen reaches out to people when they need to talk *

Never
Sometimes
Always
Not Sure

Child/Teen shares stories/memories of the deceased *

Never
Sometimes
Always
Not Sure

Do you have second child/teen to enroll?

Section Divider

Second Child/Teen

Second Child Name *

First

Last

Child/Teen speaks openly about their feelings and emotions *

Never
Sometimes
Always
Not Sure

Child/Teen asks questions about the death or deceased *

Never
Sometimes
Always
Not Sure

Child/Teen makes goals for the future *

Never
Sometimes
Always
Not Sure

Child/Teen reaches out to people when they need to talk *

Never
Sometimes
Always
Not Sure

Child/Teen displays unhealthy coping skills *

Never
Sometimes
Always
Not Sure

Child/Teen shares stories/memories of the deceased *

Never
Sometimes
Always
Not Sure

Do you have third child/teen to enroll?

Third Child/Teen

Third Child Name *

First

Last

Child/Teen shares stories/memories of the deceased *

Never
Sometimes
Always
Not Sure

Child/Teen makes goals for the future *

Never
Sometimes
Always
Not Sure

Child/Teen speaks openly about their feelings and emotions *

Never
Sometimes
Always
Not Sure

Child/Teen asks questions about the death or deceased *

Never
Sometimes
Always
Not Sure

Child/Teen reaches out to people when they need to talk *

Never
Sometimes
Always
Not Sure

Child/Teen displays unhealthy coping skills *

Never
Sometimes
Always
Not Sure

Do you have a fourth child/teen ?

Fourth Child/Teen Information

Fourth Child Name *

First

Last

Child/Teen speaks openly about their feelings and emotions *

Never
Sometimes
Always
Not Sure

Child/Teen displays unhealthy coping skills *

Never
Sometimes
Always
Not Sure

Child/Teen shares stories/memories of the deceased (copy) *

Never
Sometimes
Always
Not Sure

Child/Teen makes goals for the future (copy) *

Never
Sometimes
Always
Not Sure

Child/Teen asks questions about the death or deceased (copy) *

Never
Sometimes
Always
Not Sure

Child/Teen reaches out to people when they need to talk *

Never
Sometimes
Always
Not Sure

Do you have a fifth child/teen ?

Fifth Child/Teen Information

Fifth Child Name *

First

Last

Child/Teen speaks openly about their feelings and emotions (copy) *

Never
Sometimes
Always
Not Sure

Child/Teen displays unhealthy coping skills (copy) *

Never
Sometimes
Always
Not Sure

Child/Teen reaches out to people when they need to talk (copy) *

Never
Sometimes
Always
Not Sure

Child/Teen shares stories/memories of the deceased *

Never
Sometimes
Always
Not Sure

Child/Teen asks questions about the death or deceased *

Never
Sometimes
Always
Not Sure

Child/Teen makes goals for the future *

Never
Sometimes
Always
Not Sure

Notes or any additional explanation or observances:

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Policies & Consent for Participation

By entering your name below, you acknowledge that everything on this application is correct and you want to move forward with processing your family's enrollment to the Stepping Stones Grief Support Program.

Get Started



Enroll

Complete the Stepping Stones Membership Form



Schedule

Schedule time with our staff to discuss your needs & our support

Register

Sign-up to attend one of our activities or events

Bridges of Hope

provides a safe group environment to support & empower children, teens & their families grieving a death.

(843) 216-7323
1691 Turnbull Ave. Ste. 201, North Charleston, SC 29405
info@bridgessc.org

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Email *

What Best Describes You? *

Call Us – 843-216-7323

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