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Grief Guidance Intake Form
Full Name (Preferred Pronouns)
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Phone
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Email
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Please choose preferred contact method. Is it okay to text or leave you a private voicemail message?
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Birthday
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Month
Day
Year
Relationship Status
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Single
Married
Significant Other
Widowed
Separated
Divorced
Emergency Contact (Name, Relationship, Phone, Email)
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Who or what circumstance brings you here? Please provide dates and specifics as well as checking off all that apply on the types of loss you have experienced below.
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What kind of loss have you experienced? (Select all that apply)
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Divorce
Miscarriage
Stillbirth
Suicide
Abrupt end of Relationship
Death of Child (of any age)
Death of Mate, Spouse, Life Partner
Death of Parent
Death of Sibbling
Death of Grandparent
Death of Friend
Pet Loss/Death of Beloved Pet
Job Loss
Identity
Disability
Chronic Illness or Injury
Military Service
Incarceration (Self or family member)
Life Changing Event
Collective Grief
Domestic Violence
Have you had more than one loss in the last five years. Please describe.
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Have you experienced any events that you consider traumatic whether related to your more loss or not? If yes, please explain.
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How is your loss affecting you now? Please describe any mental, physical, emotional symptoms, quality of sleep, etc.
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Occupation/Vocation? Is your ability to work affected by your loss? Is your work a supportive environment regarding your loss?
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Are you currently in counseling or seeing a medical doctor for psychiatrist for this and/or any other condition?
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Are you currently taking any medications for depression, anxiety or other mental health issues?
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Have you ever attempted or considered suicide? If so, was there any follow up treatment? If so, please describe.
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Have you ever been hospitalized for psychiatric reasons? If yes, please explain.
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Do you live alone or with a mate? Do you have children, pets, or roommates? Please briefly describe your household and if you are content with your living situation.
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Do you experience fighting in your household? Have you ever experienced domestic violence as an adult or when you were a child? If yes, please describe.
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Do you have any injuries or disabilities that affect your quality of life at this time or that limit your ability for physical exercise or yoga? Are you pregnant?
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What is your current support system? Do you have a spiritual community? Do you attend any support groups or group therapy? In person or online?
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Please tell me what you feel you need the most, to be met where you are, to be supported during your grieving process. Please share anything else you want me to know.
Submit
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