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Home
About Us
Services
Grief Support
- Grief Support Groups & Events
- Grief Support Registration Form
Donate
- Caregiver Recognition
Volunteer
Join Our Team
- Nursing Assistant Training
News & Blog
Contact Us

Adult Intake Form

Grief Counseling Intake Form - Adult

Name
First Last
Address Line 1
Address Line 2
City
State
Zip Code
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*
Date of Birth
MM slash DD slash YYYY
Age
Emergency Contact
First Last
Relationship
Phone
Information about the Deceased
Name of Deceased
First Last
Relationship to Deceased
Date of Death
MM slash DD slash YYYY
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?
Personal Information/Life Situation
Marital Status:
- Married
- Divorced
- Single
- Widowed
- Other
please specify
Household Members/Significant Others
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Are you currently working?
- Yes
- No
What kind of work do you do?
Please list any mental health concerns/diagnosis:
Are you currently receiving counseling services from another provider?
- Yes
- No
Therapist Name
Therapist Phone
Have you seriously considered or attempted suicide?
- Yes
- No
Please explain:
Have you been hospitalized for physical/mental health reasons within the last 5 years?
- Yes
- No
Please explain:
Please list any current medical conditions:
Please list any current medications you are taking:
Have you ever abused drugs or alcohol?
- Yes
- No
Please explain:
People who are grieving may experience any of the following symptoms. Do any of these apply to you?
- Irritability
- Fatigue
- Weight gain or loss
- Change in appetite
- Nightmares/Insomnia
- Headaches
- Loneliness
- Hallucinations
- Poor concentration
- Restlessness
- Excessive guilt
- Hopelessness
- Excessive worry
- Tension/Stress
- Health problems
- Sexual problems
- Confusion
- Alcohol/Substance use
- Decreased energy
On a scale of 1-5, please check the number that best describes your experience at this moment.
Not True True
I understand how grief is affecting me.
I understand how grief is affecting me.
- 1
- 2
- 3
- 4
- 5
I have tools to cope with my grief effectively.
I have tools to cope with my grief effectively.
- 1
- 2
- 3
- 4
- 5
I can handle the intense feelings that go with grief (i.e. guilt, anger, fear, sadness).
I can handle the intense feelings that go with grief.
- 1
- 2
- 3
- 4
- 5
I know what kind of support I need in my grief and where to find it.
I know what kind of support I need in my grief and where to find it.
- 1
- 2
- 3
- 4
- 5
I believe that I can go on living and loving even though my loved one is gone.
I believe that I can go on living and loving even though my loved one is gone.
- 1
- 2
- 3
- 4
- 5
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?
Preferences
Please know that we will do our best to accommodate but cannot guarantee availability.
Location:
- Home
- Counseling Office
- Phone/Video Counseling
Day of week (mark all that apply):
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Time of day (mark all that apply):
- Morning
- Afternoon
- Evening
Consent
Consent
I consent to allow Colorado VNA to collect the information on this form.
*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.
Name
This field is for validation purposes and should be left unchanged.