Family Orientation Questionnaire

    (Please fill in the following tables)

    Which group you want to join?

    Dallas Fort Worth

    Please list all participating family members, including self (adults, teens, children)

    Optional:

    Family Nationality (ies): (Please check appropriate box or boxes)

    Adult Form

    Check which one applies:


    Check which one applies:


    Check which one applies to the custody of your children


    What emotions have you been experiencing since the divorce?

    Since the divorce, have you experienced any physical symptoms?


    Taking any medications?


    Are you seeing a counselor?


    Child Form

    Since the divorce, I want to be by myself:


    Since the divorce, school has been:


    Since the divorce, I get along with my friends:


    Since the divorce, I get along with members of my family:


    Since the divorce, my sleep is:


    Since the divorce, I eat:


    Since the divorce, I sometimes have physical hurts (headaches, stomachaches, rashes . . .)


    What emotions have you been experiencing since the divorce?

    Do you see a counselor or private therapist?

    At school?


    Outside of school


    Teen Form

    How have the areas of your life been affected since the divorce:

    What emotions have you been experiencing since the divorce?

    Since the divorce, have you experienced any physical symptoms?


    Taking any medications?


    Are you seeing a counselor?


    Family Agreement Form

    Before completing and signing this form, please read and discuss with the adults, children and teens who want to participate at KidWorks.

    • We understand that KidWorks provides support groups, not therapy or counseling.
    • We agree to attend our group regularly. If we miss more than two consecutive sessions except for illnesses or crisis, we may be dropped. We agree to call when we are unable to attend our group.
    • We agree that a child or teen must always be accompanied and supervised by a parent or another adult. We agree to always have a parent or another adult remain at KidWorks while the child or teen is in a group. We understand the adult has the option of participating in the adult support group.
    • We have read and understand the Family Agreement Form. We have discussed this information and agree to abide by the guidelines of KidWorks.

    Permission Form

    To communicate ChristianWorks for Children mission and message we often want to use quotations, stories, artwork and other artistic expressions of the children and teens for display boards, brochures, newsletters, lectures or training. The last name and detailed information about the child or teen are not spoken or printed.

    Photographs, video or audio recordings, or interviews will NOT be used without you and your child/teen giving us written permission.

    Your Rights To Privacy And Exceptions To Privacy

    Our work with you and your family at ChristianWorks for Children is confidential. Information shared with the staff, volunteers and other participants is private. Your rights to privacy will be strictly maintained. There are, however, some important exceptions to privacy which are explained on the back.

    Please read the seven exceptions to privacy on the back before signing below.

    In signing this document, I acknowledge that I have had the opportunity to ask questions about ChristianWorks for Children’s Confidentiality Policy. I have read and understand the “Right to Privacy and Exceptions to Privacy” information. I fully understand and accept my rights to privacy and the exceptions to rights to privacy.

    Seven Exceptions to Privacy

    Exception #1

    Texas law requires our staff to report to the appropriate government agency any suspected physical, sexual, or emotional abuse or neglect.

    Exception #2

    If we learn that someone with whom we are working has a specific intent to bring harm to him/herself, we reserve the right to inform other family members and/or make appropriate referrals if necessary.

    Exception #3

    If we have reason to be concerned about the drug and/or alcohol use or abuse by a child or teen, we reserve the right to inform the parent.

    Exception #4

    If information is ordered by the court, including a subpoena, we will attempt to contact you about the order. If you oppose the release, the court may nevertheless require compliance with the order.

    Exception #5

    If we learn that someone participating in the program might commit a violent act, we may take steps to protect the intended victim against such danger or inform police, or both.

    Exception #6

    The rights and exceptions to privacy apply to information disclosed in support groups. All group members are encouraged to keep such information confidential, but ChristianWorks for Children cannot guarantee they will do so.

    Exception #7

    At times, ChristianWorks for Children uses case examples of children or teens and their families in publishing articles, conducting professional training, community education, and in fund raising efforts. We may anonymously refer to your situation in those circumstances. Your child, teen or family’s complete name will never be used without your specific written approval.

    Christian Works for Children

    2214 Hemphill Street Fort Worth, TX 76110

    Ph. 817-502-7789

    Authorization For Release Of Information

    If you want a staff member of KidWorks to speak to another professional or anyone else about any of your family members, please complete this form, sign it with a witness, and have the witness sign and date. Complete a separate form for each child/teen or organization to whom you authorize a release of information.

    I authorize the staff of KidWorks to release information to:

    I understand this transfer of information is for the purpose of benefiting my family in our divorce support at KidWorks.

    Rules for Safety

    KidWorks has nine rules developed to ensure the physical and emotional safety of the children and families.

    • Stop Rule: “Stop and I mean it.” When someone is doing something that feels unsafe to anyone, that child/teen needs to stop the activity immediately.
    • Throwing Rule: Throwing soft objects is allowed only. Hard objects may not be thrown anywhere at KidWorks. When objects are thrown, they must hit below the shoulders.
    • Put-Down Rule: No hurting other people’s feelings by making fun of them, name calling or put-downs. Respect each other and self.
    • Hitting Rule: Children/Teens may hit the pillows or stuffed animals, but may not hit another person.
    • Adult Rule: Children/Teens must be with an adult at all times while at KidWorks. They may not leave the building unless accompanied by an adult.
    • Blood Rule: Children/Teens are instructed not to touch blood. In the event that bleeding occurs, children/teens are to tell an adult who will clean up the spill.
    • Privacy Rule: What is said at KidWorks is private and confidential, and stays here (exceptions are state-required reporting laws).
    • I Pass Rule: Children/teens can always “pass” if they do not want to talk.
    • Listening Rule: We respectfully listen to each other, being considerate enough to allow everyone to have an opportunity to talk, if they so choose.

    Rights of Children of Divorce

    Adapted from a decision of the Wisconsin Supreme Court expanded by Judy Branch, M.S.C.F.C.S. and Lawrence G. Shelton, PhD

    The right to be treated as interested and affected persons, not as pawns or possessions.

    The right to love each parent, without feeling guilt, pressure or rejection.

    The right to love, care, discipline and protection from both parents.

    The right not to be asked to choose sides or decide where they want to live.

    The right to express their feelings about the divorce, such as anger, sadness or fear.

    The right to a positive and constructive on-going relationship with each parent.

    The right not to have to make adult decisions.

    The right to remain children, without being asked to take on parental responsibilities or to be adult companions or friends tot heir parents.

    The right to the most adequate level of economic support that can be provided by the best efforts of both parents.

    The right not to be drawn into the painful games parents play to hurt each other.

    The right not to be put in the middle of parents’ battles.

    The right to learn appropriate behavior from their parents’ examples.

    The right to make friends and participate in school and community activities.

    The right to succeed in school and prepare themselves for independence.

    The right to know their origins and to form a personal identity based on their experiences.

    KidWorks Philosophy

    When children are confronted with divorce in their families it makes for a painful experience. Hurting children deserve to be happy and healthy in their emotional, spiritual, physical and mental state of being. KidWorks offers children of divorce and their parents the support they need and deserve through the healing process.

    • We believe that marriage is a God-established and blessed institution that was meant to last a lifetime. Unfortunately, some marriages do not. The results of divorce are often devastating to children and parents alike.
    • We believe that children need special help to overcome the losses and changes in their life due to a divorce. Many losses occur which can result in extreme grief for families of divorce. Children need support as they grieve losses and changes in their life. It is likely that the adults in their lives who are also coping with the divorce may not be able to be present for them emotionally. We want to teach them how to handle their losses rather than allowing their losses to handle them. KidWorks sessions will help children and their parents deal with their feelings and teach them coping mechanisms as they heal from their emotional wounds and struggles.
    • We believe that children of divorce have rights and that those rights should be honored. We want to remain unbiased for the sake of each child and their particular situation. Therefore, we do not take sides, but rather offer our love, support and encouragement to each child. To educate parents and children involved in our program, we will present a documented list of “Children’s Rights of Divorce” to each family participating in the KidWorks program.
    • We believe that families who are hurting in times of divorce need to recover. We exist to see families through a difficult time and help them start on the road to recovery. We offer hope and healthiness.

    “God heals the brokenhearted and binds up their wounds.” Psalm 147:3

    Help us build healthy homes and families.

    ChristianWorks for Children is a 501(c)(3) non-profit — EIN: 75-1246028.
    With your support, we can continue Jesus Christ’s example of service. Partner with us today!

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