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Pre-Registration Family Application Form

Please be aware that we do not offer one on one therapy appointments Our program is a peer support group offered to children ages 5-17 who have suffered the loss of an immediate family member. 

We also do request that families applying have a buffer period of at least 3 months after the death before attending their first meeting. We have found that when families start our program too soon, they can feel overwhelmed and then feel discouraged from coming.

If you have further questions please feel free to contact us:


Phone: (203) 634-0500 

Pre-Registration Questions

Please answer the questions below so we can make sure you qualify for our Family Program.


Would the children attending be between the ages of 5-17?

Select an option

Our program and the activities provided are focused around the death of an immediate family member. If the deceased is not an immediate family member, it may be someone who was instrumental in the child's life (for example living with the child and/or helping raise them). 

With that said we are also willing to assess the family dynamic on a case by case basis to see if your family would be a fit for our program. Please explain the relationship of the deceased to the child below. 

What is the relationship to the child of the person(s) they have lost?

Thanks for submitting!
We’ll contact this person only in case of emergency.

If you would prefer to have an application sent to your home address please call our main office at

(203) 634-0500.

**Please be aware the mailing process will take longer.**

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