1:1 Peer Support Request Form

Personal History Information

Please correct the errors described below.

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

Family Members Living with You

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Emergency Contact Information

Information About the Deceased

Anticipation Level

Personal Occupation Information

Personal Education Information

Religious Background

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?

Loss Related Changes

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


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.

Emotional History

Past / Current Legal Issues

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.