Consent for Grief Support Services

Please read this form. Ask questions about anything that you do not understand before you sign.

Grief support services are facilitated by Grief Trained individuals who have gone through a grief training process with Bereavement and Grief Specialists. Grief Trained individuals possess diverse backgrounds and may include teachers, counselors, social workers, police officers, and nurses. 

Benefits of grief support services may include the following:

• Ability to process and learn about one’s grief in a safe and welcoming environment with others who are also experiencing a death or loss. 
• Developing skills and strategies to manage one’s ongoing experience with grief.
• Opportunity to normalize one’s feelings by discussing them with others.
• Ability to gain and establish support systems.

I understand and/or agree to the following:

• Children’s Wisconsin provides voluntary education and support groups, not therapy or counseling.
• I and/or my child will attend regularly and will notify Children’s Wisconsin if I/we/they are unable to come to group.
• An adult must accompany a child or teen and remain on-site during group.
• I have read and understand the privacy considerations below.
• Children’s Wisconsin reserves the right to end services in the event that your needs or the needs of your child exceed our capabilities.

Risks and Privacy Considerations:

• Children’s Wisconsin staff and volunteers are required to report to the appropriate individuals any suspected physical, sexual, or emotional abuse or neglect.
• If Children’s Wisconsin learns that someone with whom we are working has a specific intent to bring harm to himself or herself, we reserve the right to report to the appropriate individuals.
• If Children’s Wisconsin has reason to be concerned about the drug and/or alcohol use or abuse by a child or teen, we reserve the right to inform the parent or caregiver.
• Group members are encouraged to keep group discussions confidential, but Children’s Wisconsin cannot guarantee they will do so.

In consideration of my or my child’s participation in the activity listed above, I (and my child, if I am signing as parent or guardian) release Children's Hospital and Health System, Inc. and its affiliated entities, and their respective officers, directors, employees, agents and volunteers (“Children’s”) from any and all liability or claim for loss, injury or illness that my child may sustain during my child's participation in this activity. I understand that this release applies to myself (or my child) and my (or my child's) personal representatives, heirs and assigns, and that this release excludes any harm or loss caused intentionally or recklessly by Children’s. I (and my child, if I am signing as parent or guardian) also waive the right I (or my child) have to bargain for different release of liability terms.

I have read this information.  I am legally able to consent for myself or my child.  By checking the box above, I give my permission and agree to the terms.