1:1 Peer Support Request Form

Contact GrieveWell with questions or concerns

734-975-0238
christy@grievewellpeercounseling.com

Thank you for reaching out to Grievewell. We know that you are suffering, and we are here to help.

We believe that nobody should grieve alone, and hope that we can provide support along your grief journey.

Please fill out the personal history form for 1:1 peer support. If you have any questions or need help filling out the form, please don’t hesitate to contact us.

Personal Contact Information

Name (First, Last)

Date of Birth

Age

Address

Email address

Phone Number

Family Members Living with You

Add new row

Emergency Contact Information

Name

Phone

Relationship

Information About the Deceased

Other

Years with Deceased

Deceased Name

Age

Date of Birth

Date of Death

Cause of Death

Illness

Suicide

Accident

Homicide

Drugs

Other

Anticipation Level

Sudden or Expected

Sudden Expected

Preparation Level

Not Prepared Prepared

Personal Occupation Information

Past or Current Occuption

Length of Employment

Personal Education Information

Highest Level of Education Completed

Degree(s)

Religious Background

Does religion and/or spirituality play and important role on your life?

Yes No

Religious Affiliations

Beliefs

Normal Symptoms of Grief

The grieving process impacts all areas of a person's life. The symptoms are similar to the signs and symptoms of long-term stress. Which of the following symptoms did you notice in yourself at the time of your loss?

Mental

Forgetfulness

Dull senses

Poor concentration

Low productivity

Negative attitude

Confusion

Spacing out

Lack of motivation

Sense of presence

Spiritual

Emptiness

Loss of faith

Doubt

Loss of direction

Loss Related Changes

Since your loss, have you noticed any changes related to:

Sleeping or Eating Patterns

Describe

Drug use (Including over the counter and street drugs). List drugs and frequency of use.

Describe

Caffeine Use

Describe

Smoking

Describe

Alcohol Consumption

Amount generally consumed before loss

Amount you currently consume

Is this an area of concern?

Gambling Problems

Describe

Other Concerns

Describe

How have you dealt with other losses and/or stresses in the past?

What other sources of emotional support do you have? (e.g., extended family, friends, church or other organizations?)

Therapy

Have you ever worked with a therapist?

Yes No

Are you currently working with a therapist?

Yes No

Name of therapist/agency:

Address

Phone Number

Most Recent Date Seen

NOTE: If client currently works with a therapist and/or psychiatrist, GrieveWell requires an “Authorization for Release of Information” to be signed and on file in our office.

Have you discussed your interest in GrieveWell's services with your therapist?

Yes No

How has therapy helped you?

Emotional History

Has any doctor ever prescribed you medication for depression or anxiety?

Yes No

If yes, what are your current prescribed medications?

Have you ever been hospitalized because of emotional problems?

Yes No

Do you have a history of depression?

Yes No

Have you ever felt suicidal?

Yes No

Are you suicidal now?

Yes

If checked yes, please contact 911, go the nearest emergency room

Have you had these feelings in the past?

Yes No

Have you told anyone else about this?

Yes No

Have you ever thought about hurting others?

Yes No

Past / Current Legal Issues

Have you ever been convicted of a felony?

Yes No

Have you ever been on probation?

Yes No

If yes, what's the probation officer’s name?

GrieveWell respects the privacy of clients. Your personal information will only be accessible to GrieveWell staff and will not be shared or used for purposes outside of the GrieveWell Peer Counseling Program.

After completing this form you will be contacted by our Program Director within one week to review the information and discuss our services.

Your information will be encrypted.

1:1 Peer Support Request Form

Contact GrieveWell with questions or concerns

Personal Contact Information

Family Members Living with You

Emergency Contact Information

Information About the Deceased

Anticipation Level

Personal Occupation Information

Personal Education Information

Religious Background

Normal Symptoms of Grief

Loss Related Changes

Therapy

Emotional History

Past / Current Legal Issues

Contact GrieveWell with questions or concerns

Christy Miller, LMSW, ACSW

Program Director, GrieveWell