Brief Grief Questionnaire for Dr. Kennedy
This is a brief form developed by Katherine Shear, M.D. and Susan Essock Ph.D. ©University of Pittsburgh 2002
which we've adapted for our use.  Please fill it out to the best of your ability and choose "Submit" to send your results to Dr. Kennedy.
Sign in to Google to save your progress. Learn more
First & Last Name *
Age *
For the questions that follow, please type the name of the person you're grieving for: *
1.  How much are you having trouble accepting the death of this person? *
Required
2.  How much does your grief (sadness and longing) interfere with your life? *
Required
3.  How much are you having images or thoughts of this person when s/he died or other images or thoughts about this person that really bother you? *
Required
4.  Are there things  you used to do when this person was alive that you don't feel comfortable doing anymore, that you avoid?  Like going somewhere you went with him/her, or doing things you used to enjoy together?   Or avoiding looking at pictures or talking about this person?  How much are you avoiding these things? *
Required
5.  How much are you feeling cut off or distant from other people since this person died, even people you used to be close to like family or friends? *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms