Happenings – Pre-Group Questionnaire _________________________________________ Print your full name Please print your name above. Next to each feeling or thought listed below, please circle the number that best matches how you feel right now or since the death. 0 = None 1 = A little or some 2 = Between some and a medium amount 3 = Medium 4 = Between medium and strong 5 = Strong 0
1
2
3
4
5 School changes, “My grades have changed since the death. They’ve gone up or down.”
0
1
2
3
4
5 Shock, “I still can’t believe this happened”
0
1
2
3
4
5 Guilt, “I wish I could have said or not said something, or done or not done something”
0
1
2
3
4
5 Abandonment, “I feel like they left me here all by myself”
0
1
2
3
4
5 Sadness, “I feel sad, low or blue” or “I feel like I want to cry.”
0
1
2
3
4
5
0
1
2
3
4
5 Anger at self, “It’s my fault my loved one died”
0
1
2
3
4
5 Anger at others, “It’s your fault he/she died”
0
1
2
3
4
5 Anger at God, “It’s God’s fault this happened”
0
1
2
3
4
5 Confusion, “Why did this happen?”
0
1
2
3
4
5 Numbness, “I don’t seem to feel anything”
0
1
2
3
4
5 Hopelessness, “I don’t have hope for the future or that things will change.”
0
1
2
3
4
5 Sleeping problems, “I can’t fall asleep/stay asleep” or “I sleep a lot more.”
0
1
2
3
4
5 Appetite change, “I eat more” or “I eat less” and or “I eat more comfort foods.”
0
1
2
3
4
5 Difficulty concentrating, focusing, or paying attention, “I can’t remember what you just told me.”
0
1
2
3
4
5 Relief, “I am glad that it is over.”
0
1
2
3
4
5 Loneliness, “I feel alone” or “I feel like no one understands me.”
0
1
2
3
4
Supported, “I have friends and/or family who I feel comfortable talking about the death with.”
5 Thoughts about your own death or hurting yourself “I think about my own death or hurting myself” (if 1, 2, 3, 4, or 5, please describe on the back) Written, compiled, and created by Michelle A. Post, LMFT, (revisions from Planet Kid) Page 1
Written, compiled, and created by Michelle A. Post, LMFT, (revisions from Planet Kid)
Page 2
Happenings – Post-Group Questionnaire _________________________________________ Print your full name Please print your name above. Next to each feeling or thought listed below, please circle the number that best matches how you feel right now or how you have changed since the death. 0 = None 1 = A little or some 2 = Between some and a medium amount 3 = Medium 4 = Between medium and strong 5 = Strong 0
1
2
3
4
5 School changes, “My grades have changed since the death. They’ve gone up or down.”
0
1
2
3
4
5 Shock, “I still can’t believe this happened”
0
1
2
3
4
5 Guilt, “I wish I could have said or not said something, or done or not done something”
0
1
2
3
4
5 Abandonment, “I feel like they left me here all by myself”
0
1
2
3
4
5 Sadness, “I feel sad, low or blue” or “I feel like I want to cry.”
0
1
2
3
4
5
0
1
2
3
4
5 Anger at self
0
1
2
3
4
5 Anger at others
0
1
2
3
4
5 Anger at God
0
1
2
3
4
5 “Why did this happen?”
0
1
2
3
4
5 Numbness, “I don’t seem to feel anything”
0
1
2
3
4
5 Hopelessness, “I don’t have hope for the future or that things will change.”
0
1
2
3
4
5 Sleeping problems, “I can’t fall asleep/stay asleep” or “I sleep a lot more.”
0
1
2
3
4
5 Appetite change, “I eat more” or “I eat less” and or “I eat more comfort foods.”
0
1
2
3
4
5 Difficulty concentrating, focusing, or paying attention
0
1
2
3
4
5 Relief
0
1
2
3
4
5 Loneliness, “I feel alone” or “I feel like no one understands me.”
Supported, “I have friends and/or family who I feel comfortable talking about the death with.”
0 1 2 3 4 5 Thoughts about your own death or hurting yourself (if 1, 2, 3, 4, or 5, Written, compiled, and created by Michelle A. Post, LMFT, (revisions from Planet Kid)
Page 3
please describe on the back of this page)
Written, compiled, and created by Michelle A. Post, LMFT, (revisions from Planet Kid)
Page 4
Cuestionario de Pre-Consejería _________________________________________ Escriba su nombre complete en letra de molde
______________________ Fecha
Junto a cada emoción o pensamiento que aparece abajo, por favor circule el número que más coincide cómo se siente ahora o cómo se ha sentido después de la muerte.
No cambio
He cambiado mucho 1 = He cambiado algo o un poco 2 = Entre un poco y un poco más 3 = Medio 4 = Entre medio y mucho
0
1
2
3
4
5 Cambios de escuela, “Mis grados han cambiado desde la muerte. Han subido o han bajado.
0
1
2
3
4
5 Conmoción/choque, “Todavía no puedo creer lo que ha pasado.”
0
1
2
3
4
0
1
2
3
4
5 Culpabilidad, “Me hubiese gustado haber dicho algo o no haber comentado.” Me hubiese gustado haber hecho algo o no.” 5 Abandono, “Me parece que me han dejado solo(a), sin nadie”
0
1
2
3
4
5 Tristeza, “Me siento triste, deprimido(a), penoso(a)” o “Me siento con deseos de llorar.”
0
1
2
3
4
5 Apoyo, “Tengo familia/amigos con quien me siento cómodo(a) hablando sobre la muerte.”
0
1
2
3
4
5 Ira hacia a mí mismo(a)
0
1
2
3
4
5 Ira hacia a otros
0
1
2
3
4
5 Ira hacia a Dios
0
1
2
3
4
5 “¿Por qué sucedió esto?”
0
1
2
3
4
5 Entumecimiento, “No siento nada”
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
5 Desesperanza, “No tengo ninguna esperanza para mi futuro y no me parece que las cosas van a cambiar.” 5 Problemas con el Sueño, “No me puedo dormir/quedarme dormido” o “Duermo mucho más que antes.” 5 Cambio de apetito, “Yo como más” o “como menos” y/o “como más comida que me hace sentir cómodo(a)” 5 Tengo dificultad concentrándome, enfocándome, o poner mi atención
0
1
2
3
4
5 Tengo un sentido de alivio
0
1
2
3
4
5 La soledad, “Me siento solo(a) o me siento incomprendido(a).”
0
1
2
3
4
5 Pensamientos sobre su muerte o pensamientos en hacerse daño/ herirse (si tiene alguno de estos sentimientos, por favor descríbalos atrás de esta hoja)
