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Participant Intake Form

Potential Participant Relationship to Murder Victim
Potential Participant’s Contact Information
Phone (Home) (Work) (Cell)
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