Family Bereavement Support Assessment
Family Information
Family Name
Date of Assessment
Assessor's Name
Family Members Present
Details of Bereavement
Name of Deceased
Date of Death
Relationship to Family
Brief Circumstances of Death
Current Support
Existing Support Systems
Involvement of Extended Family or Community
Family Needs Assessment
Emotional Reactions Observed
Coping Skills Noted
Identified Risks (e.g., isolation, mental health concerns)
Actions & Referrals
Support/Interventions Provided
Referrals Made
Further Follow-Up Required
Comments / Additional Notes