Grief Self Assessment Scale - Responsible Gambling

- Step 1 of 3

1. Client Information

1.1. Full Name *

First

Last

1.2. Contact Number *

1.3. Age *

1.4. Province *

2. Relationship to the deceased

2.1. What is your relationship to the deceased? *

3. 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: *

3.2. In the past few weeks, months, how often have you felt yourself longing or yearning for the person you lost? *

3.3. In the past few weeks, months, how often have you tried to avoid reminders that the person you lost is gone? *

3.4. In the past few weeks/months, how often have you felt stunned, shocked, or dazed by your loss? *

4. 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)? *

4.2. Have you had trouble accepting the loss? *

4.3. Has it been hard for you to trust others since your loss? *

4.4. Do you feel bitter over your loss? *

4.5. Do you feel that moving on (e.g., making new friends, pursuing new interests) would be difficult for you now? *

4.6. Do you feel emotionally numb since your loss? *

4.7. Do you feel that life is unfulfilling, empty, or meaningless since your loss? *

4.8. Have you experienced a significant reduction in social, occupational, or other important areas of functioning (e.g., domestic responsibilities)? *

4.9. Do you blame yourself or do your feel responsible for the death of *

Name