Please enable JavaScript in your browser to complete this form. - Step 1 of 31. Client Information1.1. Full Name *FirstLast1.2. Contact Number *1.3. Age *1.4. Province *2. Relationship to the deceased2.1. What is your relationship to the deceased? *FatherMotherDaughterSonHusbandWifeFiance Next3. Measuring Grief, kindly tick what is appropriate or what describes your feelings at the moment.3.1. Please indicate how many months have elapsed since your loved one’s death: *less than 1 month1 to 6 months6 to 12 months12 to 24 months24 months or more3.2. In the past few weeks, months, how often have you felt yourself longing or yearning for the person you lost? *not at allat least onceat least once a weekat least once a dayseveral times a day3.3. In the past few weeks, months, how often have you tried to avoid reminders that the person you lost is gone? *not at allat least onceat least once a weekat least once a dayseveral times a day3.4. In the past few weeks/months, how often have you felt stunned, shocked, or dazed by your loss? *not at allat least onceat least once a weekat least once a dayseveral times a dayNext4. For each item, please indicate how you currently feel?4.1. Do you feel confused about your role in life or feel like you don’t know who you are (i.e., feeling that a part of yourself has died)? *not at allslightlysomewhatquite a bitoverwhelmingly4.2. Have you had trouble accepting the loss? *not at allslightlysomewhatquite a bitoverwhelmingly4.3. Has it been hard for you to trust others since your loss? *not at allslightlysomewhatquite a bitoverwhelmingly4.4. Do you feel bitter over your loss? *not at allslightlysomewhatquite a bitoverwhelmingly4.5. Do you feel that moving on (e.g., making new friends, pursuing new interests) would be difficult for you now? *not at allslightlysomewhatquite a bitoverwhelmingly4.6. Do you feel emotionally numb since your loss? *not at allslightlysomewhatquite a bitoverwhelmingly4.7. Do you feel that life is unfulfilling, empty, or meaningless since your loss? *not at allslightlysomewhatquite a bitoverwhelmingly4.8. Have you experienced a significant reduction in social, occupational, or other important areas of functioning (e.g., domestic responsibilities)? *NoYes4.9. Do you blame yourself or do your feel responsible for the death of *not at allslightlysomewhatquite a bitoverwhelminglyNameSubmit