Potential Participant	Relationship to Murder Victim

Potential Participant’s Contact Information
Phone (Home)		(Work)		(Cell)
E-mail:
Mailing Address:

Victim’s Name	Date of Death	Age at Time of Death	Birthday

Cause of Death	Criminal Charges Laid/Incarceration?	Additional Information

Additional Information Regarding Potential Participant

Working at Present (Y/N)	Occupation	Primary Language

Current Stressors/Issues	Counselling at Present (Y/N)

Previous Groups Attended	What Motivates You To Attend This Group?

Any Special Needs We Should Be Aware Of?	Support System(s) (Professional, Spiritual, Family, Friends?)

General Remarks