Healing Camps Form | Fort Worth Connect

Healing Camps for Trauma-Affected Families Form

Personal and Family Information

Full Name of each family member attending the camp

Attendees Information

Contact Information

Address

Country/Region

Address

City

Zip / Postal code

Emergency Contact Information

Medical and Health Information

Any medical conditions or allergies for each family member

Current medications or treatment plans

Relevant mental health history

Any special accommodations needed for physical, emotional, or mental health support during the camp

Trauma History Overview

Brief description of the trauma the family has experienced (to ensure the camp counselors understand the context, though detailed disclosure is not required)

Current challenges the family is facing as a result of the trauma (e.g., emotional, behavioral, or relational issues)Long answer

Therapeutic Goals

What the family hopes to achieve during the healing camp

Specific challenges each family member is dealing with that they would like to address

Counseling and Support Needs

Any previous or current counseling the family or individual members have received

Preferences for counseling sessions

Preferences for therapeutic approaches

Parental/Guardian Information (for children participants)

Consent from parents or guardians for children under 18 to attend the camp

Yes

Any specific concerns parents/guardians have regarding their child’s emotional or physical well-being during the camp

Availability and Participation Information

Preferred dates for attending the camp

Confirmation of commitment to the full camp duration (including attendance at all sessions and activities)

Post-Camp Follow-Up Preferences

Interest in continued support after the camp (e.g., referrals for ongoing counseling, participation in follow-up programs)

Yes

Mentorship or additional resource needs for continued healing and support after the camp experience

Yes