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Grief Assessment Form Template

Understand your emotional journey with our grief assessment form

Feeling overwhelmed by grief can be isolating, but understanding your feelings is the first step towards healing. This Grief Assessment Form Template helps you explore your physical, cognitive, emotional, and behavioral responses to loss, guiding you through your personal grieving process. You can use it to identify your coping mechanisms, reflect on your emotions, and communicate your needs with professionals, support groups, or loved ones. Plus, it's designed to maintain confidentiality and meet accessibility standards, ensuring a respectful experience. Try out this live template to start your assessment journey.

Use this Template (FREE) Live Preview
What is your age?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
If you prefer to self-describe your gender, please specify (optional).
How do you describe your gender?
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Who did you lose? (Select all that apply)
Please Specify:
When did the loss occur?
Less than 1 month ago
1-3 months ago
3-6 months ago
6-12 months ago
1-2 years ago
More than 2 years ago
Prefer not to say
What were the circumstances of the loss? (Select all that apply)
Expected (e.g., after illness)
Sudden or unexpected
Traumatic (accident or violence)
Suicide
Overdose
COVID-19 related
Unsure
Prefer not to say
Other
Please Specify:
Have you experienced more than one significant loss in the past two years?
Yes
No
How often have you felt intense longing or yearning for the person who died?
Never
Rarely
Sometimes
Often
Always
How often have you been preoccupied with thoughts or memories of the person?
Never
Rarely
Sometimes
Often
Always
How often have you had difficulty accepting the death?
Never
Rarely
Sometimes
Often
Always
How often have you avoided reminders of the loss (places, people, activities)?
Never
Rarely
Sometimes
Often
Always
How often have you felt intense emotional pain related to the loss (such as sorrow, anger, or bitterness)?
Never
Rarely
Sometimes
Often
Always
How often have you felt that your identity or sense of self has changed since the loss?
Never
Rarely
Sometimes
Often
Always
How often have you had trouble moving forward with life or making plans?
Never
Rarely
Sometimes
Often
Always
How difficult has it been to carry out your usual daily responsibilities?
Very difficult
Difficult
Neutral
Easy
Very easy
In the past two weeks, how often have you had sleep problems (trouble falling or staying asleep, or sleeping too much)?
Never
Rarely
Sometimes
Often
Always
In the past two weeks, how often have you noticed changes in appetite or weight?
Never
Rarely
Sometimes
Often
Always
In the past two weeks, how often have you had difficulty concentrating?
Never
Rarely
Sometimes
Often
Always
I feel supported by people around me.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Are you currently receiving professional support for your grief (e.g., counseling, therapy, support group)?
Yes
No
Which forms of support are you currently using or open to using? (Select all that apply)
Please Specify:
How interested are you in receiving additional grief support (e.g., counseling, group, resources)?
Very unlikely
Unlikely
Neutral
Likely
Very likely
In the past two weeks, have you had thoughts of harming yourself?
Yes
No
Would you like to be contacted about support options?
Yes
No
Full name (optional)
Email (optional)
I consent to be contacted using the details I have provided.
Yes
No
I agree to the collection and use of my information according to the privacy policy.
Yes
No
Date
I confirm I am 18 or older, or I have permission from a parent or guardian.
Yes
No
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paper art illustration representing a grief assessment form for FormCreatorAI article

When to use this form

Use this form during intake or check-ins after a death, pregnancy loss, major breakup, or other significant loss. It helps you surface risk, understand daily impact, and plan care for clients, students, patients, or employees. In clinical settings, pair it with a broader Mental health assessment form to capture co-occurring concerns. When mood or worry seems high, add the PHQ-9 & GAD-7 form to screen depression and anxiety. For ongoing reflection between sessions, invite journaling with the Mental health journal form. In military or first-responder units, it supports consistent check-ins after line-of-duty losses and guides referrals.

Must Ask Grief Assessment Questions

  1. What loss did you experience, and when did it occur?

    Timing and context help you distinguish typical acute reactions from prolonged or complicated responses. It also guides when to offer follow-ups, memorial rituals, or stepped-up care.

  2. Since the loss, how often have you felt intense sadness, anger, guilt, or numbness?

    Tracking these emotions over time shows severity and patterns, which informs your care plan. If low mood is persistent, pair this with the Beck depression inventory questionnaire form to guide next steps.

  3. How is your grief affecting your sleep, appetite, concentration at work or school, and relationships?

    Functional impact helps you triage urgency and choose the right level of support. It also clarifies where to focus interventions, such as sleep, workload, or family communication.

  4. Have you had thoughts of self-harm or not wanting to live?

    This identifies immediate safety risks so you can create a safety plan and escalate care. Clear answers here drive rapid referrals and crisis support when needed.

  5. What support do you have now, and what support would you like (family, peers, groups, counseling)?

    Understanding strengths and preferences helps you match resources and set goals that fit. For service members or veterans, align your plan with the Army counseling form.

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