Grief Group Screener

Name*

First NameLast Name

DOB*

DOB

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Below is a set of brief questions related to your experience of grief that will help us to determine if a group therapy setting is appropriate for your needs at this time. We understand that grief is profoundly difficult and that answering these questions may prompt strong feelings. While the questions are required to move forward, we encourage you to only provide as much detail as you feel comfortable sharing. Additionally, we encourage you to attempt these questions with supportive individuals on hand or readily available should they prove difficult. Should you need direct assistance and support to answer these questions, let us know and we will work to identify a supportive approach.

Question 1: What kind of grief are you experiencing? (Whowhat have you lost and what happened to them/it?)*

Question 2: When did this loss happen? What (if anything) have you done so far in the grieving process?*

Question 3: What are you hoping to get out of this group?*

Question 4: Have you been in a therapy group before? If so, what worked for you and what did not work?*

Question 5: Attendance is important for group therapy. Would you be able to commit to attending at least 8 out of 10 sessions with a closed group (barring unexpected illness or emergency)?*

Question 6: Regarding this weekly group, please provide your availability (days and times). Please note that insurance regulations prohibit attending two different therapy sessions on the same day*

By signing, you are re-confirming your interest in DBH's grief group and attesting to the answers provided in Questions 5 and 6 regarding attendance.

Signature Signature*