Peer Grief Companion Donor Family Questionnaire

Please answer the questions below honestly so we can make sure a Peer Grief Companion will meet your needs.
Thank you,
Elissa Berman
Manager Bereavement Services

1. Please provide your name and age. *This question is required.

2. Please provide your address, phone number and email. *This question is required.

3. Please provide your loved ones name, date of birth, date of death and your relationship to them. *This question is required.

4. Is there a faith you identify with? If yes, what is it? *This question is required.

5. Is there an ethnicity you identify with? If yes, what is it? *This question is required.

6. What is your employment status? *This question is required.

7. Are your basic needs being met? (housing, food and clothing) *This question is required.

8. Before your loss, did you experience depression and/or anxiety? If yes, please elaborate. *This question is required.

9. Before your loss, did you seek professional mental health services? If yes, what brought you to seek such services? *This question is required.

10. Are you currently taking medications for depression and/or anxiety? If yes, please list. *This question is required.

11. Do you struggle with addiction? (Alcohol, drugs, eating disorder, gambling, sex etc.) *This question is required.

12. Have you ever felt suicidal? If yes, please explain. *This question is required.

13. Do you currently feel suicidal? If yes, please dial 988 to receive the assistance you need. *This question is required.

14. Have you ever engaged in self harm? (hurting your body on purpose to relieve emotional pain) *This question is required.

15. Do you currently engage in self harm? *This question is required.

16. Do you currently receive counseling for your grief? If yes, please share why you would like a peer grief companion in addition to your current support. *This question is required.

17. Why would you like a Peer Grief Companion?

18. Is there something else you would like us to know, before we assign you a Peer Grief Companion?