GrIEF AND BEREAVEMENT COUNSELING Intake Form Section 1: Personal Details Name Date Of Birth MaleFemale Email Phone Number Address Occupation Marital Status Relationship to the Deceased Date of Loss Section 2: background Information Please describe the circumstances of your loss and the relationship you had with the deceased How have you been coping with your grief since the loss? Are there any significant life events or stressors that have impacted your grieving process? Have you received any previous counseling or support related to your grief? If yes, please provide details. Section 3: Grief Experience How would you describe your current emotional experiences related to your grief (e.g., sadness, anger, guilt, numbness)? Have you experienced any physical symptoms or changes in your behavior since the loss? What are your primary concerns or challenges in coping with your grief at this time? Section 4: Support System Who are your primary sources of support during this time of grief? Are there any specific ways in which your support system has been helpful or challenging for you? Section 5: Coping Strategies What coping strategies or activities have you found helpful in managing your grief? Are there any coping strategies that you would like to explore or develop further during counseling? Section 6: Additional Information Are there any specific goals or expectations you have for grief counseling? Are there any cultural or religious considerations that are important to you in the context of your grief and bereavement? Section 7: Consent and Agreement I understand that the information provided will be kept confidential within the limits of the law and professional ethics. I agree to participate in grief counseling and understand that I have the right to ask questions and make choices about my counseling process.
