Resource Intake Form

Thank you for taking the time to speak with us today.

We know it can be hard to talk about your experiences, and we deeply appreciate you trusting us.

Everything you share will help us better understand how we can support you or your loved one during this time.

Contact Information

First Name

Last Name

Section 1: Understanding the Loss

Can you tell us a little about who your loved one was and what made them special to you?

Would you be comfortable sharing when this loss occurred?

Additionally, was this a sudden loss, or was it something you had some time to prepare for?

Section 2: Current Emotional and Practical Needs

How have you or your child/teen been feeling recently? Are there specific challenges or emotions that stand out?

Are there particular areas where you feel you or your child/teen might need more support right now?

ie. emotional support, school adjustments, connecting with others in similar situations

Is there anything that has been helping you and your family cope or feel supported so far?

Section 3: Family and Social Environment

Can you tell us a little about your family or the child/teen’s living situation right now?

Additionally, are there other adults or family members involved in providing care or support?

Do you or your child/teen have close friends, teachers, or mentors they feel comfortable talking to?

Section 4: School, Work, and Activities

How are things going with school or work for you or your child/teen? Have there been any changes since the loss?

Additionally, are there any particular challenges with concentration, motivation, or attendance?

Are there hobbies or activities that you or your child/teen enjoy that bring some sense of normalcy or comfort?

Section 5: Resources and Next Steps

Have you or your child/teen had the opportunity to connect with grief support services before? If so, how was that experience?

Would you like us to share information about grief counseling, support groups, or other resources that might be helpful?

Is there something specific you would like to see happen through this process or any goals you have for support?

Is there anything else you’d like to ask or share with us?