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Grief Assessment

Walks through the physical, cognitive, emotional and behavioural reactions that follow a loss, page by page, using intensity scales. It then invites the person to put their beliefs about mourning and their goals for support into words. Therapists and counsellors use the results to shape a first session.

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Page 1

Name*

Nombre

Apellido

Email*

Phone number*

Fatigue

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Nausea

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Insomnia

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Dizziness

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Headaches

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Loss of appetite

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Rapid heart rate

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Overall tenseness

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Page 2

Confusion

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Hypervigilance

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Memory problems

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Lack of concentration

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Poor decision making

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Poor problem solving

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Easily reminded of the event

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Intrusive thoughts and images

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Page 3

Fear

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Guilt

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Anger

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Denial

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Anxiety

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Sadness

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Shame

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Depression

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Self-blame

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Longing

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Page 4

Agitation

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Emotional outbursts

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Avoidance of others

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Impaired work performance

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Increased need to keep busy

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Increased or decreased appetite

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Increased alcohol consumption

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Increased interpersonal conflicts

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Decreased interest in usual activities

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Excessive sleeping

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Page 5

1. My heart will always carry this wound.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

2. My mourning should centre on the person I lost; caring for myself is selfish.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

3. I must grieve alone because nobody can understand this pain.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

4. I will never be happy again.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

5. Even seeing a grief therapist will not help me feel better.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

6. If I stop longing for the person I lost, I may forget them.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

7. Moving forward would dishonour the person I lost.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

8. Loss is part of life and grief is its natural consequence.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

9. I am not broken: I am open to feeling, healing and finding integrated wellbeing.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

10. Grief can be a gateway to growth.

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Page 6

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 helping you release your grief?

6. Is there a ray of hope in all of this? If so, what is it?

7. What is not helping you release your grief?

8. Where do you feel grief in your body?

9. What would you like to achieve by working together?

10. By when?

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