Blue Butterfly School-Based Group Application
Name of School
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Office Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Facilitator (Must be master's level mental health professional)
*
Facilitator Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Facilitator Email
*
example@example.com
Facilitator Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Co-Facilitator (Must be school district employee)
*
Co-Facilitator Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Co-Facilitator Email
example@example.com
Co-Facilitator Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Administrator Who Approved Program
*
Session Information
Desired Day of Week
*
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Please pick the day of the week you plan to hold the group sessions on
Location in School (Must be private, closed-door location)
*
Number of Grieving Students Identified*
*
Grades of Identified Students
*
Is School Interested in 1 or 2 Sessions During School Year?
1
2
Submit
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