Grief Counseling Intake Assessment (Adult)

Date of Service: [Date]

Client Name: [Full name]

Date of Birth: [DOB]

Clinician: [Name, credentials]

Encounter Type: [Initial Evaluation / Intake]

Setting: [outpatient / community clinic / private practice / other]

Referral Source: [Self / PCP / therapist / EAP / family / other]

Sources of Information: [Client / collateral / records]; Reliability: [good / fair / limited] (If limited, note brief reason.)

Presenting Concern

[Chief concern in client's own words as brief quote] [Precipitating change prompting help-seeking now] [Client's initial goals for treatment] (Write as a concise paragraph beginning with the quoted chief concern.)

Loss History

• Index loss: [Relationship to deceased, nature/quality of attachment]
• Date of death: [Date] Time since loss: [X weeks/months/years] (Required for diagnostic differential; if unknown, document "Unknown" rather than omitting.)
• Cause of death: [natural/expected / sudden medical / accident / suicide / homicide / overdose / ambiguous / unknown]; Circumstances: [brief description]
• Exposure details: [witnessed death / discovered body / ICU-hospice course / first responder involvement / none] (Include only if clinically relevant.)
• Role changes since death: [financial / caregiving / parenting / household / housing / Denied / Unknown]
• Mourning/cultural rituals: [completed as expected / disrupted / modified / Unknown] (Note disruptions and reasons if applicable.)
• Prior significant losses: [list / Denied / Unknown]
• Concurrent major stressors: [list / Denied / Unknown]

Current Symptoms and Functional Impact

Symptom timeline: Onset: [immediate / delayed / gradual]; Trajectory: [improving / oscillating / persistently intense / worsening]; Triggers: [anniversaries / locations / reminders / interactions]; Acute escalation episodes: [description / Denied]

• Core grief symptoms:
  • Yearning/longing and preoccupation with the deceased: [present with brief example / Denied]
  • Intense emotional pain, guilt, anger, or bitterness: [present with brief descriptors / Denied]
  • Disbelief, identity disruption, or meaninglessness: [present with brief descriptors / Denied]
  • Avoidance of reminders or proximity-seeking behaviors: [avoidance / proximity-seeking / both / Denied]
  • Loneliness, withdrawal, difficulty re-engaging in life: [present with brief descriptors / Denied]
• Differential-relevant symptoms: (Include only if present.)
  • Depressive features: [mood / anhedonia / worthlessness / sleep / appetite / energy / psychomotor / concentration]; Duration: [X weeks/months]
  • PTSD clusters: Intrusion [present / Denied]; Avoidance [present / Denied]; Negative cognitions/mood [present / Denied]; Hyperarousal [present / Denied]; Duration: [X]
  • Prominent anxiety or panic: [features and frequency / Denied]
  • Dissociation: [type and frequency / Denied]
• Functional impact: (Quantify when possible.)
  • Work/school: [attendance, productivity, leave status, accommodations]
  • Social functioning: [isolation, conflict, relational strain, supports used]
  • Home responsibilities and self-care: [ADL/IADL changes]
  • Sleep: [onset / maintenance / early awakening / nightmares]; Schedule: [bedtime/wake]
  • Appetite/weight: [increased / decreased / stable]
  • Concentration/decision-making: [impairment specifics]

Background History

• Psychiatric history:
  • Prior diagnoses: [list / Denied / Unknown]
  • Prior therapy: [type, duration, helpfulness]
  • Psychiatric medications: [current/past agents, response, adherence]
  • Hospitalizations/ER for mental health: [yes with dates / no]
  • Self-harm or suicide attempts: [history with brief details / Denied]
  • Trauma history: [interpersonal / accidents / disasters / medical / Denied] (Document type only; avoid unnecessary detail.)
• Substance use:
  • Alcohol: [quantity/frequency, change since loss, consequences]
  • Cannabis/illicit substances: [type, frequency, consequences]
  • Prescription misuse: [agents and pattern / Denied]
  • Link to grief coping: [present / Denied]
• Medical history:
  • Conditions affecting mood/sleep: [list / Denied]
  • Current medications: [list / Denied]
  • Sleep pattern: [bedtime/wake, insomnia type, nightmares, sleep aids]
• Family history:
  • Psychiatric diagnoses: [list / Denied / Unknown]
  • Substance use disorders: [list / Denied / Unknown]
  • Suicide history: [present / Denied / Unknown]
• Psychosocial context:
  • Living situation: [alone / with family / roommates / housing instability]
  • Relationship status and dependents: [details]
  • Employment/finances: [status, stressors]
  • Cultural identity and spiritual background: [details]
• Coping and supports:
  • Current coping strategies: [helpful strategies]; [harmful strategies]
  • Social supports: [who, frequency, quality]
  • Spiritual/community resources: [utilized / available / barriers]
  • Personal strengths and values: [brief description]

(If history is limited, note "History limited" and plan to obtain records/collateral.)

Mental Status Examination

• Appearance/grooming: [description]
• Behavior/psychomotor: [calm / agitated / slowed / tearful / restless / numb-appearing]
• Speech: [rate, volume, latency]
• Mood (client-reported): [description]
• Affect: [restricted / full / labile]; [congruent / incongruent]
• Thought process: [linear / circumstantial / tangential / disorganized]
• Thought content: [grief themes, hopelessness, guilt] (See Risk Assessment for SI/HI.)
• Perceptions: [no hallucinations / grief-related experiences / other]
• Cognition: [oriented x3-4, attention, memory as indicated]
• Insight: [good / fair / limited]
• Judgment: [intact / fair / impaired]
• Engagement: [eye contact, alliance, reliability]

Risk Assessment

(Required section; do not omit.)

• Suicide ideation screening: [Tool used and result] [Client denies SI / Positive screen]
• If positive screen or clinical concern:
  • Ideation: [passive / active]; [frequency, duration]
  • Plan: [present with details / Denied]
  • Intent: [present / Denied]
  • Means access: [firearms / medications / other]; [secured / access present / Denied]
  • Behaviors: [rehearsal / preparation / none]
  • Past attempts/self-harm: [details / Denied]
  • Protective factors/reasons for living: [list] (Include brief quote if pivotal.)
• Homicidal ideation/violence risk: [Denied / present with details]
• Self-neglect or inability to care for self: [Denied / present with details]
• Overall risk level: [low / moderate / high]; [acute / chronic] (Brief clinical rationale.)
• Risk mitigation: [safety plan completed / crisis resources provided / lethal means counseling / referral to higher level of care] (Include follow-up interval and contingency instructions.)

Assessment and Formulation

[Clinical summary synthesizing: who the client is, loss and time since loss, key symptoms, functional impact, coping/supports, and current risk status] (5–8 sentences; integrate without repeating entire history.)

Working Diagnoses:

• [Problem 1]: [Diagnosis or clinical impression]
• [Problem 2]: [Diagnosis or clinical impression] (Include only if applicable.)

Differential diagnosis discussion: [Address normative bereavement vs impairing grief; Prolonged Grief Disorder considerations (time since loss, duration threshold, cultural/religious context, functional impairment); Major Depressive Disorder considerations (pervasive mood/anhedonia, worthlessness, neurovegetative syndrome); PTSD considerations (trauma exposure and symptom clusters) as applicable.] (Label as clinical considerations rather than confirmed diagnoses.)

Biopsychosocial formulation: [Predisposing, precipitating, perpetuating, and protective factors] (Optional; include if clinically useful.)

Treatment Plan

• Level of care: [outpatient routine / enhanced frequency / group + individual / IOP / PHP / inpatient] (Rationale if non-routine.)
• Therapy focus and approach: [grief-focused psychotherapy / meaning-centered / CBT for grief / trauma-focused / supportive therapy]
• Frequency and duration: [weekly / biweekly / other] for [X] weeks; reassess at [timepoint]
• Treatment goals (measurable, 2–4):
  • [Goal 1 tied to function]
  • [Goal 2 tied to function]
  • [Goal 3 tied to function]
• Client preferences and shared decision-making: [summary of preferences and agreed plan]
• Referrals: [psychiatry / primary care / support group / community resources / None indicated at this time]
• Safety plan follow-through: [steps, contacts, means safety, follow-up timeline] (Include if risk present.)
• Follow-up: [next appointment] [contingency plan if symptoms worsen]

Clinician Signature: _____________________________ Date: [Date]