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1. Have you experienced the death of a close relative (parent, child, sibling) or a close friend?  Please indicated on the bar below the intensity of the loss(es) on a scale of 1 - 10 with 10 being the most intense.

0 10
i We adjusted the number you entered based on the slider’s scale.

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2. Have you had a long term romantic relationship (or several relationships) that have ended badly?  Please indicate the intensity of the feelings you had a the end of the relationship where 10 is the most intense feeling of loss.

0 10
i We adjusted the number you entered based on the slider’s scale.

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3. Have you been sexually, physically, or emotionally abused?  Please indicate the intensity of the situation at the time of the abuse and your feelings of anger, violation, etc. on a scale of 1 - 10, where 10 is the most intense.

0 10
i We adjusted the number you entered based on the slider’s scale.

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4. How many times have you changed jobs in your life either by choice or layoff/firing?  Indicate the number of changes on the slider below.  If more than 10, choose 10.

0 10
i We adjusted the number you entered based on the slider’s scale.

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5. Do you suffer from the loss of a body part, mental illness, or chronic pain?  On the slider, indicate the intensity of the issue where 10 is the most intense.

0 10
i We adjusted the number you entered based on the slider’s scale.

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6. Do you have bad habits or behaviors that leaving you questioning why you do them?  For instance, overeating, shopping too much, video games, or sexual promiscuity/self manipulation.  On the scale, indicate the intensity of the frustration you feel with this (these) behavior(s).

0 10
i We adjusted the number you entered based on the slider’s scale.

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7. As a child (prior to 18 years), how many times did you (and your family) move?  Please indicate the number of moves on the slider bar.  If more than 10 times, choose 10.

0 10
i We adjusted the number you entered based on the slider’s scale.

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8. On a scale of 0 - 10, how well does the following statement describe you?  10 means it describes you perfectly.  0 means it does not describe you at all.  "I avoid getting close to people.  I have been burned too many times."

0 10
i We adjusted the number you entered based on the slider’s scale.

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9. On a scale of 0 - 10, how well does the following statement describe you? 10 means it describes you perfectly. 0 means it does not describe you at all.  "I don't like to talk about my lost loved one (or ex).  It stirs up too many painful memories."

0 10
i We adjusted the number you entered based on the slider’s scale.

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10. On a scale of 0 - 10, how well does the following statement describe you? 10 means it describes you perfectly. 0 means it does not describe you at all.  "I know I need help dealing with my grief and loss, but I don't know where to turn."

0 10
i We adjusted the number you entered based on the slider’s scale.

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