Grief & Loss Assessment Form

Hi there! Thanks for having the courage to complete the grief & loss assessment form!

Please be sure to answer all of the questions.

I will be in touch soon with how I can help you thrive through your pain.

Grief Will Grow You! - Cortne' Smith

On a Scale of 1 to 10, how much do rate your level of grief?

1 being the least, 10 being the most

Your Name *

First Name Last Name

Mobile Phone *

Email *

example@example.com

What's your first thought of the day? *

How many times a day do you find yourself crying?

How many conversations a week do you talk about memories you shared with your love one? Yes, Social Media Posts count!

When's the last time you we’re angry about their death?

How much time to do spend alone?

What's your stance on dating again?

Are you a routine or tradition breaker? *

Are you grieving with others over your love one? *

Would you change your last conversation or interaction with your love one? *

Do you have something that you still want to do with them? *

Feel free to leave any comments that you would like for Cortne' Smith to know.

Meet Cortne' Smith

As a professionally trained and experienced life coach, from Transformation Academy. We have the tools and understanding to help you to live your BEST life.

As a facilitator of the Prepare-Enrich & Certified Relationship Coach for Singles/Couples program, she is utilizing the most updated and top of the line equipment to provide maintenance for your Relationship Vehicle.

Cortne' has experience for hand loss and is here to help others "Thrive through Loss" and find joy, peace and love again.

Feel free to visit - www.relationshipservicestation.com

Speak to you soon!