Elizabeth Barrette (ysabetwordsmith) wrote,
Elizabeth Barrette

  • Mood:

Grief Questionnaire

After writing the post about coping with grief, I got to thinking about how Terramagne-America handles this sort of thing. As with many social aspects, they do it better. One thing I had spotted in passing earlier was the use of followup calls after bereavement, and questionnaires to identify people who would welcome such contact. That sounded really useful, so I found one and wrote it down. This is typical of handouts available at funeral parlors, hospitals, counseling centers, and other places where people may interact with death and mourning. It can also be used for self-assessment; although that approach doesn't provide the same level of support, it can still illuminate what is happening in your grief process.

Grief Questionnaire

Death brings some difficult challenges. We are sorry for your loss. We offer this questionnaire to help you think about how you are feeling and whether you have enough support. Participation is encouraged but not required. Children or people with special needs may just use the faces, or ask someone for help filling out more details. Staff are available if you have any questions or concerns. If you need help, just ask. All answers are confidential.

Short Form

Casual friends, distant relatives, and people who are doing as well as can be expected may want to fill out only the short form and aftercare section.

What was your relationship to the deceased?
( ) Immediate family: _______________________________
( ) Close friend
( ) Extended family: ________________________________
( ) Caregiver: _____________________________________
( ) Casual friend, coworker, neighbor, etc.
( ) None; here to support someone else or for another reason
( ) Other: _________________________________________

How are you doing today?

Happy ... Okay ... Sad


Long Form

Close friends, immediate family, and people who are struggling to cope with this loss may wish to fill out the long form in addition to the short form and aftercare section.

How much grief are you feeling right now?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Happy ............ Okay ............. Heartbroken
How much numbness are you feeling right now?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Emotionally Aware .. Meh .. Can't Feel Anything

How well are you coping today?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Effectively ... Sort Of ... Poorly ... Not At All

Has this death made you think about your own mortality?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
No .. Yes, but I'm okay .. Yes, I'm uneasy ..Yes, I'm fixated on death

How would you rate your fluency in mourning and death/dying issues?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Fluent ... Adequate ... Iffy ... Totally Lost

How would you rate the quality of support you are receiving?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Compassionate .. Perfunctory .. Poor .. Worse Than Useless

Is anything besides the loss itself interfering with your ability to mourn or otherwise function?
(   )  Yes: ______________________________________________________
(   )  No

Grief is a process that takes work to move through. Try to remove obstacles, practice self-compassion, and take care of yourself so that you can mourn effectively, then eventually move on with your life.

Who is supporting you in this difficult time? Check all that apply.
( ) Immediate family: ______________________________________________
( ) Close friends: _________________________________________________
( ) Extended family: _______________________________________________
( ) Neighbors and community: _______________________________________
( ) Online contacts: _______________________________________________
( ) Casual friends and coworkers: ____________________________________
( ) Support group or other social club: _________________________________
( ) Clergy or other religious help: _____________________________________
( ) Counselor or other mental worker: _________________________________
( ) Nobody seems to care
( ) None needed; here to support someone else or for another reason
( ) Other: _______________________________________________________

Nothing can make mourning easier, but social support can facilitate the process and reduce the chance of complications. The more and better support you have, the better your outcomes. Ask for help if you need more than you are getting.

Do you have any risk factors for complicated grief? Check all that apply.
( ) Previous experience of complicated grief after another death
( ) Sudden, unexpected, traumatic, violent, mysterious, and/or random death
( ) Death that seemed preventable or otherwise pointless
( ) Death that seemed like your fault
( ) Death after protracted, grievous illness
( ) Loss of a child (including abortion or miscarriage if it upsets you)
( ) Suicide loss
( ) Negative, ambivalent, or complicated relationship with the deceased
( ) Depression, developmental disability, or other mental issues that could impair your ability to mourn in a healthy manner
( ) Physical illness, injury, or other bodily issues that could impair your ability to mourn in a healthy manner
( ) You recently suffered another death (within the last 12 months)
( ) You suffered another death more than 12 months ago, but you have not yet completed the grieving process for it
( ) Disenfranchised grief or other lack of social support
( ) Other _______________________________________________________

Even one factor can cause complicated grief, or it can occur unexpectedly. The more complicating factors, the more likely it is to develop. If you have three or more of these, seriously consider getting a mental health checkup in 2-4 weeks.

Is there anything else you would like to share? ___________________________

How do you feel after completing this questionnaire?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Better ......... The Same ............ Worse



Thank you for answering our questions. We wish you healing in this difficult time. If you need more support or information, we can help you find some in a venue convenient for you.

Would you like to hear more about grief amelioration resources?
( ) Yes, please.
( ) No, thank you.

Would you like to hear more about mourning skills and other death/dying issues?
( ) Yes, please.
( ) No, thank you.

Would you like to discuss your own end-of-life plans?
( ) Yes, please.
( ) No, thank you.

May we contact you in a few days to see how you are doing?
( ) Yes, please.
( ) No, thank you.

Phone number:
Email or other electronic address:
Mailing address:

You do not need to give the complete mailing address if you don't want to, but knowing your city and state would help us to recommend resources in your area.

* * *


Terramagne-American funeral homes do not consider their job done as soon as the coffin goes into the ground. They are hubs of care and education for issues of grief, death, and dying. Hospitals and counseling centers often cover the same subject area, but each has its own approach. This way, people have multiple opportunities to learn the skills for coping with death, which everyone needs, and they can choose a venue they find tolerable.

T-America most often uses a 5-point mood scale from happy to sad/angry. For simpler situations they may use a 3-point scale, and for very complex ones they may use a 10-point scale. Establishments with a high number of less-verbal people (small children, foreigners, people with developmental or linguistic disabilities, etc.) often offer a mood scale feedback kiosk in addition to or instead of the usual feedback box. Happy or Not is a 4-point mood scale feedback kiosk. This one is a simpler 3-point version. When used properly, feedback improves social connection, service quality, and satisfaction.
Tags: community, family skills, how to, life lessons, safety
  • Post a new comment


    default userpic

    Your IP address will be recorded 

    When you submit the form an invisible reCAPTCHA check will be performed.
    You must follow the Privacy Policy and Google Terms of use.