Personal History

Personal Contact Information

Family Members Living with You

Do you have Pets?

Emergency Contact Information

Loss Experienced

Information About the Deceased

Cause of Death

Anticipation Level

Sudden or Expected

Preparation Level

Personal Occupation Information

Personal Education Information

Religious Background

Does religion and/or spirituality play an important role in your life?

Normal Symptoms of Grief and Stress

The grieving process impacts all areas of a person's life. The symptoms are similar to the signs and symptoms of long-term stress. Which of the following symptoms did you notice in yourself at the time of your loss?






Loss Related Changes

Since your loss, have you noticed any changes related to:


Have you ever worked with a therapist?

Are you currently working with a therapist?

NOTE: If client currently works with a therapist and/or psychiatrist, GrieveWell requires an “Authorization for Release of Information” to be signed and on file in our office.

Have you discussed your interest in GrieveWell's services with your therapist?

Medical History

Emotional History

Has any doctor ever prescribed you medication for depression or anxiety?

Have you ever been hospitalized because of emotional problems?


Do you have a history of depression?

Have you ever felt suicidal?

Are you suicidal now?

If yes,

Have you thought about how you would commit suicide?

When would you commit suicide?


Have you had these feelings in the past?

Have you told anyone else about this?

Have you ever thought about hurting others?

Past/Current Legal Issues

Have you ever been convicted of a felony?

Have you ever been on probation?

If yes, probation officer’s name

Once you submit this form it will be transmitted to our staff for review. A staff person will follow up with you within a week to review the information and discuss our services.

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