Family Bereavement Support Assessment
Basic Information
Assessor Name
Date
Family Member(s) Name(s)
Contact Information
Deceased Information
Name
Relationship to Family
Date of Death
Family Situation
Household Members
Circumstances Around Death
Bereavement Needs Assessment
Emotional Support Needs
Current Support Systems
Practical Support Needs
Risks and Concerns
Immediate Risks or Concerns
Children or Vulnerable Persons Concerns
Follow-up Plans
Actions to be Taken
Referrals Made
Date of Next Contact