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Tommy’s Kids/Teens for Teens Referral Form

Please contact Rosie Cohen at (630) 856-6993 to register or simply complete our online registration form. You will be contacted shortly after its receipt by a staff member to confirm your registration.

Child/Teen Name*	Date of Birth*	Grade In School*
Child/Teen 2 Name	Date of Birth	Grade In School
Child/Teen 3 Name	Date of Birth	Grade In School
Parents/Guardian*
Address*
Work Phone*		Home Phone*
Name of Person Who Died
Relationship to Child		Date of Death
Has child/teen been involved in any other group or counseling since the death? If so, please explain:
How did you hear of Tommy’s Kids/Teens for Teens?
Snacks will be provided for children. Please list any food allergies.
Regular attendance is very important to the child’s successful participation in the group. Please check below to give your permission for your child’s participation and to indicate you agree to make attending a priority.

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* Required

Adventist Midwest Health

120 North Oak Street, Hinsdale, IL 60521

Phone: (630) 856-9000

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