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Client Intake Questionnaire

Thank you for taking this important step in your healing journey. This questionnaire helps me understand where you are right now and how I can best support you. Please answer as much as feels comfortable—there’s no pressure to share more than you’re ready to.

Grief Coaching Intake

Basic Information

Full Name *

Address *

City, State, ZIP *

Phone *

Email *

Age *

Session Preferences

How would you prefer to meet? (Check one)

Virtual sessions

In-person sessions

A mix of both

About Your Loss

Name of your loved one *

Your relationship to them *

(Example: son, daughter, spouse, parent, sibling, friend, etc.)

When did this loss occur? *

If you feel comfortable, please briefly share the circumstances of your loss

(You are welcome to share as much or as little as feels right for you)

Your Support & Beliefs

Do you currently have a support system? (family, friends, support groups, therapist, etc.)

Yes

Somewhat

If yes, please briefly describe

Do you have spiritual or religious beliefs that are important to your grief journey?

Yes

Unsure

If you'd like to share more about your beliefs or practices

Where You Are Now

What symptoms or challenges are you currently experiencing?

Difficulty sleeping

Changes in appetite

Overwhelming sadness

Anger or irritability

Feeling numb or disconnected

Difficulty concentrating

Physical pain or tension

Isolation or withdrawing from others

Guilt

Anxiety or panic

Lack of energy or motivation

OtherOther

What would you like to achieve or experience by the end of our 6-week program together?

Is there anything else you'd like me to know as we begin this journey together?

If you are human, leave this field blank.