CAPABLE: Community Aging in Place – Advancing Better Living for Elders

First Name*

Last Name

Address*

City*

State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Home Phone

Work Phone

Mobile Phone

Is it OK to leave a message?

Yes

No

Is it OK to use texting for appointment scheduling/confirmations?

Yes

No

Email Address*

Date Of Birth

Age

Emergency Contact First Name

Emergency Contact Last Name

Relationship

Phone Number

First Name of Deceased

Last Name of Deceased

Relationship to Deceased

Date of Death

Age at Death

Place of Death

Cause of Death

Was the person who died a hospice patient?

Yes

No

If yes, please give the name of the hospice.

Have you experienced any other losses in the past year?

Marital Status:

Married

Divorced

Single

Widowed

Other

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Are you currently working?

Yes

No

Please list any mental health concerns/diagnosis:

Are you currently receiving counseling services from another provider?

Yes

No

Have you seriously considered or attempted suicide?

Yes

No

Have you been hospitalized for physical/mental health reasons within the last 5 years?

Yes

No

Please list any current medical conditions:

Please list any current medications you are taking:

Have you ever abused drugs or alcohol?

Yes

No

People who are grieving may experience any of the following symptoms. Do any of these apply to you?

Irritability

Change in appetite

Loneliness

Restlessness

Excessive worry

Sexual problems

Decreased energy

Fatigue

Nightmares/Insomnia

Hallucinations

Excessive guilt

Tension/Stress

Confusion

Weight gain or loss

Headaches

Poor concentration

Hopelessness

Health problems

Alcohol/Substance use

I understand how grief is affecting me.

I have tools to cope with my grief effectively.

I can handle the intense feelings that go with grief (i.e. guilt, anger, fear, sadness).

I know what kind of support I need in my grief and where to find it.

I believe that I can go on living and loving even though my loved one is gone.

Please list any support resources available to you at this time (i.e. friends, family, church, community groups,activities).

What prompted you to seek grief counseling and what are you hoping to get out of your sessions?

Anything else you would like your counselor to know about you?

Where did you hear about CVNA Grief Counseling Services?

Location:

Home

Counseling Office

Phone/Video Counseling

Day of week (mark all that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Time of day (mark all that apply):

Morning

Afternoon

Evening

Consent*

I consent to allow Colorado VNA to collect the information on this form.

Submit

*Information included on this form is protected by the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and will remain confidential between the applicant and group facilitators and will not be shared with the group without specific permission.

*Information included on this form is protected by the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and will remain confidential between the applicant and group facilitators and will not be shared with the group without specific permission.