Trustbridge Bereavement Center 

Registration and Informed Consent  

 

 

 

 

 

 

 

 

 

 

Informed Consent Statement  

I, ____________________________________, am presenting myself to TrustBridge Bereavement Center for counseling services.                    (Client Receiving Services)  

CONSENT FOR SERVICES: I hereby voluntarily consent to and authorize such services, which may include (but are not necessarily 

limited to) individual support, group support, or education, by authorized agents and employees of the facility or their designees 

as may in their professional judgment be necessary and beneficial. I acknowledge that no guarantees have been made to me as 

to the effect of such assessments or services provided. I understand I may be provided with resources and referrals if additional 

support is required.  

CONFIDENTIALITY: I understand that TrustBridge Bereavement Center clinicians maintain confidentiality of client information in 

accordance with the legal and ethical requirements of their profession.  I accept that my information may be released or reported 

under certain circumstances that are required by law (see “Client Bill of Rights and Privacy Notice”). 

RESPONSIBILITY FOR PERSONAL VALUABLES: I hereby release TrustBridge Bereavement Center from any liability resulting from 

loss by theft or negligence of mine or that of any employee.  I understand that I am fully responsible for all of my personal articles 

while at the TrustBridge Bereavement Center. 

Services in this program are rendered without distinction to race, faith, national origin, handicapping condition, age, or sexual orientation. This program complies fully with: Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975. I have been informed of my rights and have received a copy of the “Client Bill of Rights and Privacy Notice” (BER720).  By  providing  your  e‐mail  address,  you  agree  to  Trustbridge  Bereavement  Center  communicating  with  you  and  sending 

information related to Trustbridge bereavement programs. You may opt out of receiving such communications at any time by 

emailing bereavementevents@trustbridge.com. 

 The undersigned certifies that he/she has read the above paragraphs and is the client, or is duly authorized by the client as the client's general agent, to execute the above and accept its terms. 

Demographic Information  

First Name    Last Name   

Primary Phone    Email Address    

Information about the Loss 

Date of Death    Relationship to Deceased   

Cause of Death   

Was your loved one a hospice patient?  □  Yes, Trustbridge  □  Yes, Another Hospice  □  No 

If Trustbridge, please provide the patient’s name:  ___________________________________________________________        

Date: ______________________        Client's Signature:  __________________________________ 

Office Location:  Juno Beach     Boca Raton    Parent/Guardian Signature:___________________________ 

     West Palm Beach   Fort Lauderdale  Printed Name, Parent/Guardian:________________________ 

 Boynton Beach   Other ___________ 

CHILD SELF‐ ASSESSMENT 

Rev. 12/2017 

 

Name: ___________________________________________   Age: ______        Date: __________________ 

(Color or check the starfish that says how you really feel today) 

I think about the good memories            Sometimes    Always    Never 

I think about the bad memories          Sometimes    Always    Never 

I feel confused             Sometimes    Always    Never 

I have a hard time paying attention         Sometimes    Always    Never 

I have thoughts of ending my own life        Sometimes    Always    Never 

I am sleeping well             Sometimes    Always    Never 

I am eating well             Sometimes    Always    Never 

I am able to follow directions          Sometimes    Always    Never 

I’m having a harder time doing my schoolwork     Sometimes    Always    Never 

I have used drugs and/or alcohol to feel better     Sometimes    Always    Never 

I have a hard time breathing           Sometimes    Always    Never 

I have aches/pains in my body:         Sometimes    Always    Never 

I have questions about:            Sometimes    Always    Never 

I feel sad               Sometimes    Always    Never   and when I do it’s  (small)  1   2   3   4   5  (big) 

 I feel angry               Sometimes    Always    Never           and when I do it’s (small)  1   2   3   4   5  (big) 

I feel worried              Sometimes    Always    Never           and when I do it’s (small)  1   2   3   4   5  (big) 

I feel relieved              Sometimes    Always    Never    and when I do it’s (small)  1   2   3   4   5  (big)  

I feel happy               Sometimes    Always    Never  and when I do it’s (small)  1   2   3   4   5  (big) 

I feel guilty               Sometimes    Always    Never                           and when I do it’s (small)  1   2   3   4   5  (big)  Name the people who give you comfort and support:      Family: ______________________________________________ 

Friends:                    Other: _____________________________________ 

I feel the best when I:________________________________________________________________________________ 

Overall, I feel like I am doing:    0   1     2     3     4    5    6    7    8    9    10                                                                                          (Well)                   (Okay)              (Not Well) 

                                                                                                                                                             

    

Patient Name:______________________________ Office Use Only: POC Discharge POC Review Other: __________________

    MEDICATION PROFILE   

          

 

ALLERGIES:                                  NO KNOWN ALLERGIES  DATE:             

 NO CURRENT MEDICATIONS REPORTED  

MEDICATION NAME  DOSAGE  FREQUENCY  SPECIAL INSTRUCTIONS  DATE 

START/STOP 

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 BER 745    Rev. 12/16                      Client Name:            

 

Client Bill of Rights & Privacy Notice

BER 720 Rev. 03/17

DEFINITION: The Trustbridge Bereavement Center is a counseling/education program created to offer anyone experiencing concerns with grief and bereavement with the special support and guidance they may need to face the realities of loss and change. As a client, you have the right to:

Be treated with dignity, courtesy and respect.

Be fully informed of all services available to you at The Trustbridge Bereavement Center

Receive competent, individualized service from qualified Trustbridge Bereavement Center staff.

Report abusive, neglectful or exploitative practice to Florida statewide toll-free telephone number, you may call toll free 1-800-96-ABUSE (1-800-962-2873)

Make informed and self-determined decisions about the service you receive.

Receive information to help you make such decisions and to participate in developing and revising your Plan of Care.

Receive prior notice and to make an informed decision before receiving clinical service from a Master’s level graduate student or participating in any research projects.

Voice grievances, opinions, recommendations, in relation to policies and services offered by The Trustbridge Bereavement Center, without fear of discrimination or reprisal.

If at any time you are dissatisfied with your care: complaints, recommendations or grievances should be reported to:

Bereavement Manager at (561) 227-5175. Trustbridge Bereavement Center

300 Northpoint Parkway, Suite 305, West Palm Beach, Florida 33407 I also understand I have a responsibility to:

Provide accurate and complete information to The Trustbridge Bereavement Center regarding your medical, psychological, psychiatric and financial state.

To provide accurate and updated information on other health care providers from whom you may receive treatment or care.

Agree to accept staff providing services regardless of age, race, color, national origin, religion, sex, disability or any other category protected by law.

Participate in planning, evaluating and revising my care plans to the degree that I am able to do so.

Notify The Trustbridge Bereavement Center of the need to cancel or reschedule a scheduled visit a minimum of 24 hours in advance.

Client Bill of Rights & Privacy Notice

BER 720 Rev. 03/17

Privacy Under the Health Insurance Portability and Accountability Act (HIPAA)

Trustbridge protects your medical information and your rights regarding your own medical records. We are dedicated to protecting your right to privacy of your medical information, while providing the highest quality medical care. We want you to be aware of regulations that affect how we use and disclose your medical information, and the rights you have regarding your medical records. Privacy rules adopted as part of the federal Health Insurance Portability and Accountability Act (HIPAA) establish standards for the release of medical information that personally identifies you.

Our Privacy Practices

We must provide you access to a privacy notice that explains how we may use or disclose your medical information. We will ask you to acknowledge that you have received and understand our privacy notice when you are first admitted.

Your Permission

Once we have informed you about our privacy practices, you may designate to whom you want your medical information released. We may then release information about you for purposes of your treatment, billing for services, or for Hospice operations such as quality assurance without further permission from you. You may revoke your permission to use and disclose your medical information at any time.

Authorization

You may be asked to sign an authorization form allowing release of information for other purposes not related to your treatment, billing for services or Hospice operations. However, you are not required to sign an authorization form. We will not deny treatment if you elect not to sign the authorization form.

Your Rights Regarding Medical Records

Federal privacy regulations give you many rights regarding your medical records, including:

The right to an accounting of certain disclosures of your medical information. Medical records are retained for six years.

The right to inspect and obtain a copy of your medical information.

The right to receive confidential communications of your medical information by an alternative means or at an alternative location.

The right to request an amendment to your medical record.

The right to submit a complaint about how your medical information is used or disclosed.

If you have any questions about how we will use or disclose your medical information, please contact Health Information Management at (561) 227-5215.

For questions regarding your rights, or HIPAA, call our Compliance Hotline at 1 (800) 765-7408.

For additional rights and privacy information, please ask your counselor.

Children’s Developmental Stages and Reactions to Death & Dying (These are possible grief reactions based on developmental stage.

However, each child is unique and will have his or her own individual responses to loss.)

UNDER TWO YEARS OF AGE

Don’t understand what death is May sense the loss/absence of a particular person Sense the emotions around them May react physically (change in sleeping, eating, or bladder/bowel function, irritability) Won’t remember the deceased Need physical reassurance, care, affection, and routine

THREE TO FIVE YEARS OF AGE

View death as temporary - like a trip or just “less alive” Have difficulty understanding abstractions like Heaven Escape into play for relief from reality of the loss Grieve intermittently - cannot tolerate extended periods of sadness Increased aggression, acting out, fear of abandonment Regressive behavior (bet-wetting, thumb sucking, tantrums, etc.) May wonder, “Who will take care of me now?” May attach to substitute people (neighbor, relative, teacher, etc.) May not remember the deceased Need reassurance, love, care, daily routine, and structure.

FIVE TO TEN YEARS OF AGE

Begin to conceive of death as final Death seen as accidental and happening to others May personify death: a ghost, the bogeyman, and angel, etc. May feel angry or may wonder “Did I cause this to happen?” Difficulty expressing feelings in words Feelings are expressed through behavior (anger, fear, etc.) May ask concrete questions (“Why do we bury people when they die?”) Abstractions such as heaven still difficult to understand Need reassurance, love, care, daily routine, and structure.

TEN TO EIGHTEEN YEARS OF AGE

Recognize death as final and universal to all things Tend to hide feelings May attempt to take on role of the deceased - “man of the house” Fears of the future may be high Denial - trying not to think about it, not wanting to talk about it Peers are an important source of support May feel anger, repress sadness, feel depressed Religious beliefs may be questioned Fear their own death, but may also “test” it through risk-taking Need reassurance, love, care, daily routine, and structure.

How to Help a Child Deal with a Loss As soon as possible after the death, set time aside to talk with your child.

Give your child the facts in a simple manner. Be careful not to go into too much detail. The child will ask more questions as they come up in their mind.

If you can't answer his or her questions, it is alright to say, "I don't know how to answer that, but perhaps we can find someone to help us understand".

Use the correct language - say the words "dead" and "die". Do not use phrases such as, "He's sleeping..." or "God took her..." or "He went away..."

Ask questions like, "What are you feeling?" "What have you heard from your friends?" "What do you think has happened?" etc.

Explain your feelings to your children, especially if you are crying. Give them permission to cry too. We are their role models: it is good for children to see our sadness and to share our feelings with them.

Understand the age and level of comprehension of your child and speak to that level.

Talk about feelings, such as angry, sad, feeling responsible, scared, tearful, depressed, wishing to die too, etc.

Talk about the visitation period and funeral. Explain what happens there and find out if your child wants to attend with the rest of your family.

Think about ways that a child can say goodbye to the deceased, such as writing a letter, poem, drawing a picture, etc.

Talk to your child about your religious beliefs, if appropriate, and what happens to people after they die.

Invite your child to come back to you if they have more questions or have heard rumors so that you can help them receive the correct information.

Talk about memories: good ones and ones that may not be so good.

Watch for behavior changes in your child - if they are cause for concern, seek professional help.

Watch out for "bad dreams" - are they occurring often? Talk about the dreams: they are a way to discharge stress.

This information is adapted from Simpler Times - Resource Center - Grief Issues 2001

BILL OF RIGHTS CHILD/TEEN‐ANTICIPATORY AND BEREAVEMENT 

                                                   

 

MY RIGHTS For Children and Teens 

 

Counseling can inspire and motivate you to work through your grief journey and instill hope about your future. 

  

HOW DOES COUNSELING HELP AND WHY AM I HERE?  

I am in counseling to talk about my feelings and to get to know more about them.  I am unique and have the right to my own feelings about the illness or death of the person I love.   

It is okay for me to have lots of feelings.  I may feel sad, mad, happy, scared, and worried.  It is okay for me to talk and share about my feelings in safe ways.   

It is okay to talk about my loved one who is sick, or who has died and to do special things to remember this person.   

I can draw pictures, read stories, play music and talk about my feelings, and will  learn about ways to help myself. 

I have the right to have my questions and concerns regarding my counseling or the person  I love’s illness or death answered. 

  

WHAT DO I NEED TO KNOW AND DO?  

What I say in counseling is confidential, this means private.  If I am being hurt by someone, hurting myself, or hurting others, then this is shared with an 

adult who can help me.  It is okay for me to ask questions and to tell my parent, counselor, or others about what I talk 

about in counseling if I want.  I will be treated with respect and I will treat others with respect.  I will learn how to feel and 

be safe.  If I do not feel safe, I will tell someone and ask for help.  I  have  the  right  to  receive  services  from  caring,  sensitive,  knowledgeable  counseling 

professionals who will attempt to understand my needs 

      

 BER420   Rev. 12/16