Intake Form | Tears of Joy

Grief Guidance Intake Form

Welcome & Purpose

This intake form is offered as a supportive, non-clinical resource to help me better understand your experiences, current supports, and emerging intentions for grief guidance.

My work is rooted in lived experience rather than diagnosis or treatment. This form Is not intended to assess, label or reduce your experience to a diagnosis. Instead, it provides context so that our time together—if we choose to work together—can be used with care, presence, and depth, without requiring you to repeatedly recount your personal history or “back story.”

Some questions also help me determine whether grief guidance is an appropriate support at this time, or whether another form of care may better serve your needs—either prior to or alongside our work together. You are always welcome to skip any question that feels uncomfortable or not relevant. Your safety and well-being come first.

* Required

Basic Information

Full Name

Preferred Name (If different - pronouns optional)

Phone

City

State

Country

How did you hear about Tears of Joy?

Your Grief Context

Please share the loss or losses that bring you here at this time? (You may be brief. There is no requirement to share details.

How long has it been since this loss or losses occurred?

What feels most present or tender in your grief right now?

Intentions & Readiness

What is drawing you to grief guidance at this point in your life?

What intentions-if-any-feel gently emerging for you around this work? (It’s okay if this feels unclear.)

Current Support & Stability

The following questions will help me understand your current support needs and determine whether grief guidance is an appropriate and safe fit at this time.

Are you currently working with any healthcare or support providers?

Are you currently taking any medications that feel relevant to your emotional or nervous-system well-being?

Do you currently use any substances (prescribed, recreational, or self-medicating) that significantly affect your mood, energy, or daily functioning?

Safety & Care Considerations

You may skip any question in this section.

Have you ever experienced periods of emotional distress that felt overwhelming or unsafe?

Have you ever had thoughts of self-harm or suicide, past or present? (If yes, you may share only what feels relevant.)

Is there anything in your life right now that makes it difficult to manage daily activities or feel grounded?

Anything else you'd like to share (Optional)

Is there anything you’d like me to know about what brings you here or what you’re carrying at this time?

Before submitting, please review and acknowledge the following:

I understand that this form is intended to help clarify my needs, support intention for our work, and determine whether grief guidance is an appropriate fit at this time.

I understand that the information I share helps shape how support may be offered and how my needs might best be met.

I understand that, in some cases, I may be offered referrals or recommendations if another form of support would better serve my well-being.

Welcome & Purpose

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