Grief Assessment
Name
*
First Name
Last Name
Email
*
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Phone Number
*
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Format: (000) 000-0000.
Physical Reactions
Please rate your experience in each of these areas:
Fatigue
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Nausea
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Insomnia
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Dizziness
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Headaches
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Loss of appetite
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Rapid heart rate
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Overall Tenseness
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
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Next
Cognitive Reactions
Please rate your experience in each of these areas:
Confusion
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Hypervigilance
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Memory problems
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Lack of concentration
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Poor decision making
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Poor problem solving
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Easily reminded of the event
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Intrusive thoughts and images
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
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Emotional Reactions
Please rate your experience in each of these areas:
Fear
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Guilt
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Anger
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Denial
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Anxiety
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Sadness
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Shame
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Depression
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Self-blame
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Longing
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
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Behavioral Reactions
Please rate your experience in each of these areas:
Agitation
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Emotional outbursts
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Avoidance of others
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Impaired work performance
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Increased need to keep busy
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Increased or decreased appetite
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Increased alcohol consumption
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Increased interpersonal conflicts
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Decreased interests in usual activities
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
Excessive sleeping
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
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Beliefs About Grief
Please rate your experience in each of these beliefs:
1. My heart will always have this wound.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
2. My grief and mourning should be focused on my departed. Self-care is selfish.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
3. I must do grief alone because no one can possibly understand the pain I am going through.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
4. I will never be happy again.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
5. Even seeing a grief therapist is not going to help me feel better.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
6. My departed is gone. If I stop longing for them, I may forget him/her.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
7. If I move forward, that is dishonoring my departed.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
8. Loss is a part of life. Grief is a natural consequence of loss.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
9. I am not broken. I am broken open to feel emotions, heal through the guidance of the body and discover Integrated Wellbeing.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
10. Grief is a gateway to growth.
Not At All
1
2
3
4
Very Much
5
1 is Not At All, 5 is Very Much
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Diving Deep
Please complete or answer in your own words:
1. When grief overwhelms me it feels like...
2. The one thing I wish would change is...
3. My biggest fear is...
4. What I would like to have happen is...
5. What is working to release your grief?
6. Is there a ray of hope in all of this? If so, what is it?
7. What is not working to release your grief?
8. Where is grief in your body?
9. What would you like to have happen as an outcome of us working together?
10. By when?
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