Grief Impact Assessment for Children
Please answer the following questions to help assess the impact of grief on the child.
Child's Full Name
First Name
Last Name
Age of the Child
Has the child experienced the loss of a loved one?
Yes
No
How has the child been feeling emotionally?
Have there been any changes in the child's behavior or routine?
Are there any specific concerns or observations you would like to share?
On a scale from 1 to 10, how would you rate the child's overall adjustment to the loss?
1
1
2
3
4
Best
5
1 is , 5 is Best
Submit
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