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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
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First
Last
Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
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United States
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Spain
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India
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Iran
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Israel
Japan
Jordan
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North Korea
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Kuwait
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Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Email
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Phone
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Emergency Contact Name
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Emergency Contact Phone
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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.
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Charge Me $20 Deposit
Charge Me $220 For Session 1-4
Charge Me $440 For Sessions 1-8
Credit Card Number
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Expiration
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3-Digit Code
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Billing Zip Code
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Signature
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Clear