Grief Support Questionnaire
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Print your full name Date
Please print your name above. Next to each feeling or thought listed below, please circle the number that best matches how you feel right now or how you have changed since the death.
No Change A little Between some Medium Between medium Strong
None or some and medium and strong
0 1 2 3 4 5 School or Work changes, “My grades (or work) have changed since the death. They’ve gone up or down.”
0 1 2 3 4 5 Shock, “I still can’t believe this happened”
0 1 2 3 4 5 Guilt, “I wish I could have said or not said something, or done or not done something”
0 1 2 3 4 5 Abandonment, “I feel like they left me here all by myself”
0 1 2 3 4 5 Sadness, “I feel sad, low or blue” or “I feel like I want to cry.”
0 1 2 3 4 5 Supported, “I have friends and/or family who I feel comfortable talking about the death with.”
0 1 2 3 4 5 Anger at self, “It’s my fault my loved one died”
0 1 2 3 4 5 Anger at others, “It’s your fault he/she died”
0 1 2 3 4 5 Anger at God, “It’s God’s fault this happened”
0 1 2 3 4 5 Confusion, “Why did this happen?”
0 1 2 3 4 5 Numbness, “I don’t seem to feel anything”
0 1 2 3 4 5 Hopelessness, “I don’t have hope for the future or that things will change.”
0 1 2 3 4 5 Sleeping problems, “I can’t fall asleep/stay asleep” or “I sleep a lot more.”
0 1 2 3 4 5 Appetite change, “I eat more” or “I eat less” and or “I eat more comfort foods.”
0 1 2 3 4 5 Difficulty concentrating, focusing, or paying attention, “I can’t remember what you just told me.”
0 1 2 3 4 5 Relief, “I am glad that it is over.”
0 1 2 3 4 5 Loneliness, “I feel alone” or “I feel like no one understands me.”
0 1 2 3 4 5 Thoughts about your own death “I think about my own death” (if 1, 2, 3, 4, or 5, please
describe on the back)
0 1 2 3 4 5 Thoughts about hurting yourself “I think about hurting myself” (if 1, 2, 3, 4, or 5, please
describe on the back)