EmailMe Form - The Grief Recovery Method Questionnaire

The Grief Recovery Method Questionnaire

The Grief Recovery Method Group is an action program for moving beyond loss. During the sessions you will look at your old beliefs and behaviors, examine what losses you have experienced through your life; then learn and take the actions that will help you complete the pain attached to those losses.

Please feel free to complete this form as you feel comfortable. I do need your name and contact information, but the rest is at your discretion. This form is protected and confidential. I am the only one who will have access to it at any time!

Warmly,
Corinne

Name *
First Last
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Email *
Phone *
### - ### - ####
Emergency Contact Name *
First Last
Emergency Contact Phone *
### - ### - ####
Remember, you are not required to complete this portion of the questionnaire. It simply provides a brief idea as to your loss history.

Checkbox Grid

	Yes	No
Did you move more than once before age 10?
Did you ever have a pet die?
Have you experienced a major change in financial conditions (better or worse)?
Have you ever quit a job or been fired?
Have you ever been married or divorced?
Did you drop out of school or college?
Have you experienced the death of a close family member?
Have you ever been physically abused?
Have you ever been sexually abused?
Have you ever been verbally abused?
Have you ever been involved with a miscarriage, still birth or abortion?
Do you have a strained or painful relationship with a living parent, spouse, friend or colleague?
Do you harbour any resentments or ill-feelings towards a deceased parent, spouse, friend or relative?
Have you ever experienced the loss of use or function of any part of your body?
Have you ever experienced the death of a Spouse or partner?
Are there long stretches of your childhood that you cannot remember?
Have you experienced a series of illnesses or accidents?
Have you been involved in a series of unsuccessful relationships?

Any Loss History You'd Like To Share?
Because Space Is Limited, A Deposit of $20 Is Required To Hold Your Spot For The Grief Recovery Method Group. Each session is $60. Payment Is Required At Each Session.

Save $40 With These Two Options.
1) Pay Sessions 1-4 At The Same Time & Save $20. Later Pay Sessions 5-8 At The Same Time & Save Another $20!
2.) Pre-Pay 8 Sessions and Save $40 At One Time. *
Credit Card Number *
Expiration *
3-Digit Code *
Billing Zip Code *
Signature *
Clear

Remember, you are not required to complete this portion of the questionnaire. It simply provides a brief idea as to your loss history.