Grief Counseling Consent and Intake Form

Personal Information

Full Name

Date of Birth

Address

Phone Number

Emergency Contact Name

Emergency Contact Phone

Grief/Loss Information

Who have you lost? Relationship to you Date of Loss Briefly describe your loss and current feelings

Counseling Goals

What do you hope to achieve through grief counseling?

Relevant History

Have you previously attended counseling? Please describe any relevant medical or mental health history

Consent

I consent to participate in grief counseling and understand the information provided will be kept confidential except where disclosure is required by law.

Signature

Date