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Peer Grief Companion Questionnaire
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1.
Please provide your name and age.
(Required.)
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2.
Please provide your address, phone number and email.
(Required.)
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3.
Please provide the name of your loved one, their date of death and your relationship to them.
(Required.)
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4.
Is there a faith you identify with? If yes, what is it?
(Required.)
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5.
Is there an ethnicity you identify with? If yes, what is it?
(Required.)
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6.
What is your employment status?
(Required.)
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7.
Are your basic needs being met? (housing, food, clothing)
(Required.)
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8.
Before
your loss, did you experience depression and/or anxiety? If yes, please elaborate.
(Required.)
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9.
Before
your loss, did you seek professional mental health services? If yes, what brought you to seek such services?
(Required.)
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10.
Are you currently taking medications for depression and/or anxiety? If yes, please list.
(Required.)
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11.
Do you struggle with addiction? (alcohol, drugs, eating disorder, gambling, sex etc. )
(Required.)
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12.
Have you ever felt suicidal
before
your loss? If yes, please elaborate.
(Required.)
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13.
Do you currently feel suicidal? If yes, please dial 988 to receive the assistance you need.
(Required.)
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14.
Do you currently receive counseling for your grief?
(Required.)
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15.
Why would you like a peer grief companion?
(Required.)
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16.
Is there something else we should know, before we assign you a peer grief companion?
(Required.)