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Personal Grief Assessment This self-survey can help you assess your current stress level as your loved one declines and aid you in determining if you could benefit from outside bereavement support.
1. Day-to-Day Challenges Please circle any scenarios that apply. In the last month, I have: a. Had difficulty making decisions for my loved one or myself. b. Felt completely overwhelmed. c. Had the feeling that I am not helpful or doing enough to care for my loved one. d. Felt alone. e. Felt like my siblings are not doing as much as they should. f. Felt like I am doing the majority of caregiving with no “thank you” from family members. g. Felt upset or hopeless because my loved one has changed so much from his or her former self. h. Been edgy or irritable. i. Felt I haven’t had enough sleep, or as a caregiver, I haven’t been able to get the rest I need. j. Had crying spells. k. Increased: • Smoking. • Drinking. • Medication that was prescribed to me, but am taking more of it. Name of medication and why it was prescribed:
2. Status Check Please circle ‘YES’ or ‘NO’ in response to each question below. Are you a single parent? YES NO Do you feel angry or very frustrated?
YES
NO
Are you feeling so angry that you could hurt yourself or others?
YES
NO
Are you caring for young children at home?
YES
NO
Have you had any other significant losses in your family or close friends?
YES NO
As your loved one’s health changes and you anticipate the days ahead, YES NO do you fear that you will need more skills and knowledge than you currently have? Considering the changes that are happening in your family, are you YES NO worried that soon you may not have a stable place to live? Are you concerned that there may not be resources for food and YES NO living expenses?
INSTRUCTIONS: To use the scale below, combine the number of scenarios circled in section 1 with the number of ‘YES’ answers in section 2. 1-3 You’re on a good path, but it may still be helpful to reach out for some advice. 4-5 Now may be the time to focus more on yourself; you could benefit from some care and support. 6+ You may be experiencing some overload. Caregiver stress is very normal, and bereavement support can help you process new ways to release stress and understand the transition process.
Residential Hospice offers one-on-one as well as group grief support. For more information, call (866)902-5854 and ask for Bereavement.
The contents of this Residential Hospice self-survey are for informational purposes only. The content is not intended to be a substitute for professional psychological, psychiatric, or medical advice, diagnosis, or treatment. Consult with your physician, psychiatrist, psychologist, or other qualified health provider without delay to gain more information regarding your specific medical and/or psychological needs.