Grief Assessment

Please fill the below Assessment Form

1) Have you lost someone significant to you? * YesNo

2) What is your loved one’s name? *

3) What month and year did your loved one die? *

4) What was the deceased’s cause of death? *

Please explain

4.1) Since the suicide death of your loved one, or as a result of their suicide, do you struggle with answering the question “why did they do it?” * YesNo

5) Since the death of your loved one, do you find it difficult to accept your loved one died? Not at allSlightlyNeutralQuite a bitOverwhelmingly

6) Since the death of your loved one, do you feel you have given yourself permission to grieve? Not at allSlightlyNeutralQuite a bitOverwhelmingly

7) Since the death of your loved one, do you feel you have given yourself permission to heal? Not at allSlightlyNeutralQuite a bitOverwhelmingly

8) Since the death of your loved one, or as a result of their death, do you fear being judged by others on how you grieve? Not at allSlightlyNeutralQuite a bitOverwhelmingly

9) Since the death of your loved one, or as a result of their death, do you fear that you will not be able to live without your loved one? Not at allSlightlyNeutralQuite a bitOverwhelmingly

10) Since the death of your loved one, do you fear forgetting your loved one and/or others will forget them? Not at allSlightlyNeutralQuite a bitOverwhelmingly

11) Since the death of your loved one, or as a result of their death, do you question if you will ever experience peace, joy, and happiness again? Not at allSlightlyNeutralQuite a bitOverwhelmingly

12) Since the death of your loved one, or as a result of their death, are you experiencing increased physical illness, aches and pains, and new health diagnosis? Not at allSlightlyNeutralQuite a bitOverwhelmingly

13) Since the death of your loved one, or as a result of their death, are you experiencing increased stomach issues, difficulty sleeping and problems with eating? Not at allSlightlyNeutralQuite a bitOverwhelmingly

14) Since the death of your loved one, or as a result of their death, do you have difficulty focusing on day-to-day tasks? Not at allSlightlyNeutralQuite a bitOverwhelmingly

15) Since the death of your loved one, or as a result of their death, do you feel depressed? Not at allSlightlyNeutralQuite a bitOverwhelmingly

16) Since the death of your loved one, or as a result of their death, has your usage/consumption of alcohol/drugs increased? Not at allSlightlyNeutralQuite a bitOverwhelmingly

17) Since the death of your loved one, or as a result of their death, have you lost interest in activities you once enjoyed? Not at allSlightlyNeutralQuite a bitOverwhelmingly

18) Since the death of your loved one, or as a result of their death, have you withdrawn from family/friends and tell yourself no-one understands what you are going through? Not at allSlightlyNeutralQuite a bitOverwhelmingly

19) Since the death of your loved one, or as a result of their death, has your relationship with your higher power (God, Universe, etc. - the something that you believe in that explains the unexplainable) changed? Not at allSlightlyNeutralQuite a bitOverwhelmingly

20) Since the death of your loved one, have you felt your loved one’s presence? Not at allSlightlyNeutralQuite a bitOverwhelmingly

21) Your Name *

22) Email Address *

Please leave this field empty.

99389

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+1(888) 985-7299
[email protected]

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[email protected]

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Quick Links

Home
Why Suicide
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Meet Peggy
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