Fire Affected Grieving Family Intake Form - Nā Keiki O Emalia

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Nā Keiki O Emalia

Grief Support for Children and Teens

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Fire Affected Grieving Families Intake

Contact Details

Parent or Guardian(Required)

First Last

Email(Required)

Phone

Address(Required)

City ZIP / Postal Code

How would you like to be contacted?

Email

Text

Phone

Did someone important to you and/or to the children die because of the fires?

Yes

No

Other

Interview notes about the death associated with the fire.

Did someone important to you and/or to the children die before the fires?

Yes

No

Other

Interviewer notes about the death not associated with the fire.

How many grieving children are under your care?

NOTE: If they are reluctant to give names and birthdates try to find out the school(s) the keiki will be attending.

1st Childs Name

Child 1

Date of Birth

MM slash DD slash YYYY

School

Child's Name

Child 2

Date of Birth

MM slash DD slash YYYY

School

Child's Name

Child 3

Date of Birth

MM slash DD slash YYYY

School

Child's Name

Child 4

Date of Birth

MM slash DD slash YYYY

School

Child's Name

Child 5

Date of Birth

MM slash DD slash YYYY

School

Would your Keiki be better served in a Program

At School

At a Community Center

No Preference

Would you be interested in attending an adult group alongside the keiki group?

Yes

No

Maybe

NOTE: We offer adult groups at the same time as keiki groups in a separate area when the groups are held in a community center but not at the schools.

Do you want more information on grieving support groups and resources for adults?

Yes

No

Maybe later

NOTE: On our site is a list of Adult Grief Support Groups in Hawaii under services.

Grief Support Groups Hawaii

They will also be receiving an email with a lot of different resources including the adult grief groups.

Are you experiencing?

Potential Houslessness

Food Insecurity

Electrical or Utility Shut Off

Mortgage or Lease Difficulty

Job Loss

Job Loss Due to Bereavement

Other

Would you like a Keiki Care Package Delivery?

Yes

No

Maybe

Interviewer Notes

Email list

Would like to join our email list?

Comments

This field is for validation purposes and should be left unchanged.

Δ

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Contact

Cameron Center
95 Mahalani St – Room 10
Wailuku, HI 96793

Mail:
PO Box 1137
Wailuku, HI 96793

Phone:
(808) 214-9832

Email:
contact@nkoemaui.org

Nā Keiki O Emalia is a
501(c)(3) nonprofit organization
ID 47-3859477

Helping Children Heal

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