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Your Details

First Name

Last Name

Pronouns

Pronouns - other (please specify)

Date of Birth

Age

Mailing Street

Town/City

County

Postcode

Phone number

Email Address

Ethnicity

Please specify

Which gender do you identify with

Please tell us

Do you have any religious or spiritual beliefs?

YesNo

If so, please share?

Do you have any physical health issues or disabilities we should be aware of?

YesNoPrefer not to say

If yes, please expand?

What is your main language?

Please specify

Which doctor’s surgery are you registered with?

How did you hear about Child Bereavement UK?

If Other, please specify

Who do you live with? Please include ages/relationships as appropriate.

Please think about your mental health needs. Are you presently receiving any support or are you on a waiting list for your mental health needs (including CMHT, MIND, private therapy, etc)?

Have you ever had counselling/art therapy/play therapy/music therapy or any other type of talk therapy before?

YesNo

If Yes, please tell us when this was and what this was for.

Are there any ongoing safeguarding concerns that we should know about, including any involvement by social services?

YesNo

If Yes, please tell us more.

Are you currently involved in any investigations, inquests or legal processes?

YesNo

If Yes, please tell us more.

Thinking about your use of alcohol, drugs or other substances. Has this changed since the death?

YesNo

If so, how?

Please provide details about the child who has died

First name of child who has died

Last name of child who has died

Who was this person to you?

If Other, please specify

When did they die?

How old was this child when they died?

How did they die?

Is there anything else you want to tell us about how they died?

Anything further you’d like to share about the circumstances of death?

How would you describe your main reasons for seeking support now?

Please tell us about how you have been since this child died, including how you are managing daily life (work, relationships, sleep, concentration)?

Please tell us who you go to for support

Please tell us about any other significant life events

Do you have any worries about your feelings?

Do you have any worries about your behaviour?

Please select how you feel about each statement below

	Strongly Agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
1. I feel able to face the pain which comes with loss
2. For me, it is difficult to switch off thoughts about the person I have lost
3. I feel very aware of my inner strength when faced with grief
4. I believe that I must be brave in the face of loss
5. I feel that I will always carry the pain of grief with me
6. For me, it is important to keep my grief under control
7. Life has less meaning, for me after this loss
8. For me, it's best to avoid thinking about my loss
9. It may not always feel like it but I do believe that I will come through this experience of grief

AAG Score

Over the last week...

Please select how you feel about each statement below

	Not at all	Only occasionally	Sometimes	Often	Most or all of the time
1. I have felt tense, anxious or nervous
2. I have felt I have someone to turn to for support when needed
3. I have felt able to cope when things go wrong
4. Talking to people has felt too much for me
5. I have felt panic or terror
6. I have made plans to end my life
7. I have had difficulty getting to sleep or staying asleep
8. I have felt despairing or hopeless
9. I have felt unhappy
10. Unwanted images or memories have been distressing me

Can you tell us more why you have been thinking about ending your life

Can you tell us who you have shared your thoughts of self-harm/suicide with, if anyone?

CORE-10 Score

Can you advise when would be best to call you, should we need to get in touch?

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