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!

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

  • 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?