Grief Intake Form - Deb Lee Gould, MEd 2026

1. Click ‘Get Form’ to open the Grief Intake Form in the editor.
2. Begin by filling in your personal details such as Name, Age, and Sex. This information helps tailor the support you receive.
3. Provide your contact information including Home Phone, Cell, and Email Address. Ensure these are accurate for effective communication.
4. Indicate if you are currently working with a therapist or medical professional regarding grief. If yes, provide their name and contact number.
5. List the names and birth/death dates of your deceased loved ones. This section is crucial for understanding your grief context.
6. Reflect on past losses and coping mechanisms learned from family. This insight can guide your healing process.
7. Detail any current difficulties you are experiencing related to grief. Be honest; this will help in providing appropriate support.
8. Finally, save the completed form as a PDF. You can then email it, print it to fax, or bring it to your appointment.

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