Bereavement Support Intake Form

Bereavement Support Intake Form

*Indicates required question
Email
example@example.com
Welcome

Parten
I consent to sharing the following information with the Stedman Community Hospice Supportive Care Team
Contact Information
Name

First NameLast Name
Phone Number (home)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (cell)
Please enter a valid phone number.Format: (000) 000-0000.
Preferred method of contact
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pronouns (she/her, he/him, they/them etc.)
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Bereavement Information
Which bereavement support group are you interested in at this time?
Have you ever participated in a bereavement support group/program?
How did you hear about the bereavement support service offered at Stedman Community Hospice?

Other
Name of deceased
Deceased's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of death

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The deceased was my...

Other
Did the deceased receive palliative care?
If yes, where did the deceased receive palliative care?

Other
If no, where did the deceased die?

Other
The loss was...
If this loss was sudden/unexpected, what was the manner of death?

Other
How do you feel you are coping with the loss? On a scale of 1-10, select the number that best describes how well you are coping today.

1

2

3

4

5

6

7

8

9

10

1 is Not , 10 is Coping well
What are your current coping mechanims/strategies?
Are you currently or have you ever seen a mental health professional?
If yes, please elaborate:
Are you currently experiencing or have you ever experienced any other losses (e.g., another death, breakup/divorce, job loss, financial hardship, move, etc.). If yes, please describe:
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is there any other information you would like the Supportive Care Team to know?
Should be Empty:

Bereavement Support Intake Form

Welcome

Contact Information

Bereavement Information