Intake Form: Grief & Art Group - Southwest Counselling Services

Thank you for taking the time to complete this intake form. The details of this form are confidential and will be kept in a secure location. We use this information to ensure we have appropriate resources and tools to support you in your grieving journey.

Personal Information

Date*

Name*

Date of Birth*

Gender*

Home Address*

Phone Number(s)*

May we leave a message?* YesNo

Email Address*

Are you currently working?* YesNo

If yes, in what field?

Do you have health benefits that cover social work or counselling services?* YesNo

May we send you emails about the group and upcoming programs/events?* YesNo

How did you hear about this group?*

Emergency Contact

Emergency Contact Name*

Relationship*

Address

Phone Number*

Medical Information

Family Doctor*

Do you have an existing health condition that would increase your risk in participating in light physical movement? Ie. Cardiovascular issues, Joint issues* YesNo

If yes, please consult your doctor prior to commencing this group.

Do you have a current mental health diagnosis? (ie. Depression, Anxiety, PTSD, Complicated Grief Disorder etc.)* YesNo

If yes, and you feel comfortable, please list the diagnoses:

Bereavement Information

If Other, please specify:

How long ago did your loved one pass away?*

Symptoms

Counselling and Support History

Have you attended any counselling, groups, or community-based programs to help cope with your grief?* YesNo

If yes, please describe:

Coping Strategies

How are you currently coping with this loss? Please share any healthy or unhealthy strategies you are using:*

What have you found most helpful in dealing with your loss?

Additional Details

What is your sleep routine like?

Do you meditate?*
YesNo

If yes, can you share your practice? If no, are you open to trying it?

Do you have any experience with art?

Would you want to express yourself with colour or black and white in your painting?*

Do you remember your dreams?*
YesNo

Do you keep a journal of your dreams?*
YesNo

Are you open to talking about your dreams?*
YesNo

How often do you spend time in nature?

Are you open to exploring nature in our sessions?*
YesNo

Are you open to exploring how to integrate spirituality with your grieving process?*
YesNo

What do you do when you are alone?

What are your interests and hobbies? Do you have any favorite books, movies, sports, or things to do?

Preferred time slots:
9-11am10-12pm11-1pm