Adult Night Intake Questionaire

Date

DOB

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone

Other Phone

Employers Name

How did you hear about The Alcove?

Name of the Deceased

How are you related to the deceased?*

Date of Death

Cause/Circumstance of Death

Location of Death

Please explain how you are doing in the following areas since the death: (Check the best answer)

Work/Career

More Difficult
Less Difficult
Same

Social Life/Friendships

More Difficult
Less Difficult
Same

Sleeping Habits

More Sleep
Less Sleep
Same

Eating Habits

Eating More
Eating Less
Same

Relationships with Children

More Difficult
Less Difficult
Same

Financial Problems

More Difficult
Less Difficult
Same

Other Relationships

More Difficult
Less Difficult
Same

Explain

What emoitions have you experienced since the death?

Since the death, have you had any physical problems for which you are seeking medical treatment?

Yes
No

If yes, please describe

Physician Name, Address & Phone:

Are you taking any medication(s)?

Yes
No

Specify Medications

Are you currently seeing a therapist or counselor?

Yes
No

Are you involved with any social service agency?

Yes
No

Explain

Besides this death, have you had other changes or losses that your family has experienced? (Moved, Changed Schools, Other deaths?)

Yes
No

Explain

How do you feel you have been coping with this death?

Do you have friends/family who you can freely share your grief with?

Family

Yes
No

Friends

Yes
No

Is there any particular concern for yourself you would like to address in joining our program?

Additional Comments

Adult Night Intake Questionaire

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Adult Night Intake Questionaire

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