Stepping Stones Referral

Building bridges of hope for lowcountry families since 1980

Are you the caregiver (parent or guardian)?

How did you hear about us?

Why are you referring this child/teen to Stepping Stones Grief Support Program?

Caregiver Contact Information

Parent/Guardian Name *

First

Last

Parent/Guardian Email

Parent/Guardian Phone

Best way to reach Parent/Guardian?

Is this Parent/Guardian Spanish Speaking Only ?

We offer some communications in Spanish, including a welcome email, enrollment forms, welcome letter w/ brochures & phone calls if Spanish is requested. Although we do not provide services in Spanish, we can pair a Spanish speaking families with a Spanish speaking volunteer at events, if requested. A Spanish speaking volunteer will be in contact with the family by phone if we do not get a response via email.

Child/Teen Information

How many child(ren)/teens in the same family are you referring?

Majority of our programs are open to ages 7-17

Child/Teen Name

First

Last

Referral Source Information

Referral Source Name

First

Last

Title

School, Organization or Agency Affiliation

Contact Number

Have you discussed our program with the parent or guardian?

Yes
No, please notify the family of the referral prior to our contact.

Is there anything else you would like us to know ?

Comment