Grief Questionnaire -- Candyce Ossefort-Russell, M.A., LPC

GRIEF QUESTIONNAIRE

Are these words or tears?
Is weeping speech?
— Rumi, The Essential Rumi, translated by Coleman Barks

Introduction

I am currently in the preliminary stages of writing a book about the way people’s lives can change and be transformed by grieving, and how this kind of transformation is helped along by sharing our grief with other people, by having our mourning held and witnessed. To enrich this book, I’m really interested in learning about many people’s experiences of grief. I would like to know if you feel you have been damaged by or grown from your grief and loss, what kind of social support you have had in dealing with your grief, how your social support affected your grieving, etc.

If you would like to participate in my research for this book, I invite you to complete the following questionnaire. At the end of the 31 questions, you’ll have the opportunity to tell me whether you’d like to remain anonymous or whether you’d like me to know who you are. You’ll also be given the opportunity to discuss your experiences in more depth in an interview with me.

If you choose to go ahead with the questionnaire, I thank you for sharing your experiences in this way. I believe sharing and learning from each other helps us all grow.

Questionnaire

Please answer the following questions based on your experience of the death of a particular loved one. If you have lost more than one beloved person, you may fill out the questionnaire more than once to differentiate between your grief experiences at different times and through different losses.

1)	How long ago did you lose your loved one to death?
		0-6 months 6 months to 1 year 1-2 years 2-5 years more than 5 years

2)	How was your loved one related to you?
		spouse or partner father mother child sibling friend other (please specify below)
		enter text here

3)	Was the death sudden or expected?
		sudden expected

4)	Was the death due to natural or unnatural causes?
		natural causes (please specify below) unnatural causes (please specify below)
		enter text here

5)	When your loved one died, did you participate in rituals such as a funeral or memorial service? (Check all that apply)
		visitation
		wake
		funeral or memorial service
		burial service
		other (please specify below)
		enter text here

6)	Did you find the rituals helpful or comforting in your distress?
		yes no I did not participate in rituals

7)	If you answered yes to #6, please write a sentence or two about what was helpful or comforting to you:
		enter text here

8)	If you answered no to #6, please write a sentence or two about what was not helpful or comforting to you:
		enter text here

9)	Did you or do you still have social support in the immediate aftermath of the death of your loved one (from 0-6 months)?
		yes, plenty some, but I wish I had more no, not much other (specify)
		enter text here

10)	Did you or do you still have ongoing social support during the longer term of healing from your loss (from 6 months to 5 years or more)?
		yes, plenty some, but I wish I had more no, not much other (specify)
		enter text here

11)	Are you or were you encouraged to express your feelings about your loss in the first six months after the death of your loved one?
		yes, a lot yes, a little no, my feelings were overlooked no, my feelings were discouraged

12)	Are you or were you encouraged to express your feelings about your loss and your ongoing life changes after 6 months to more than 5 years following the death of your loved one?
		yes, a lot yes, a little no, my feelings were overlooked no, my feelings were discouraged

13)	If you did have social support following your loss, from whom were you receiving it? (Check all that apply)
		spouse or partner
		grown children
		parents
		siblings
		other family members
		friend(s)
		therapist
		minister, rabbi, or other clergy
		a community (e.g. church, neighborhood, etc.)
		support group
		other (specify)
		enter text here

14)	Did you find the social support that you received immediately following your loss (0-6 months) adequate for your needs?
		yes no

15)	Did you find the social support that you received in the longer term after your loss (6 months to >5 years) adequate for your needs?
		yes no

16)	Were you able to allow yourself to receive the help or comfort that was offered to you?
		yes, most of the time yes, some of the time not really not at all I was not offered help

17)	Were you able to ask for help or comfort when you needed it?
		yes, whenever I needed it yes, on some occasions hardly ever never

18)	Did you or do you feel able to handle your feelings of mourning and its accompanying life changes when you were/are by yourself?
		yes, I like working things out alone yes, but I don't like being alone with my feelings yes, I need some time alone AND some time with others no, the feelings are overwhelming and they scare me no, so I turn off my feelings when I'm alone

19)	If your loved one died less than 1 year ago, how would you say you’re coping with your loss at this time?
		I'm fine, it's not a problem I'm struggling a little bit It's very difficult, but I'm surviving It's very difficult, and I don't know how I'm going to make it I'm completely overwhelmed Other (specify)
		enter text here

20)	If it’s been more than one year since your loved one died, how would you say the loss has fit into your life? (Check all that apply)
		I’m struggling, but I’m making a new life for myself
		It will always hurt in one way or another, yet I’m seeing ways I’ve grown from the experience
		I’m still overwhelmed, but I can see value in the struggle
		I’ll never feel better again and I don’t want a new life
		Other (specify)
		enter text here

21)	Do you feel like the social support your did or did not receive 0-6 months after your loss has affected your ability to cope with it in the short and/or long term?
		yes no

22)	If you answered yes to #21, please say a little bit about how social support has affected your ability to cope:
		enter text here

23)	Do you feel like the social support your did or did not receive 6 months to more than 5 years after your loss has affected your ability to cope with the loss and integrate it into your life in the short and/or long term?
		yes no

24)	If you answered yes to #23, please say a little bit about how social support has affected your ability to cope and integrate:
		enter text here

25)	From my experience with loss, I feel better able to be with others if they lose a loved one.
		agree disagree

26)	Going through this grief process has changed my sense of self.
		yes, for the better yes, for the worse no, not at all

27)	Going through this grief process has changed my relationships with others.
		yes, for the better yes, for the worse no, not at all

28)	Going through this grief process has altered my philosophy of life.
		yes, for the better yes, for the worse no, not at all

29)	If you could tell another person or the whole world one thing about how this loss has affected you, what would it be?
		enter text here

30)	You can quote me in your book.
		yes, but don't use my name yes, and you can use my first name (enter below) no, please do not quote me
		enter text here

31)	I would like to be contacted by Candyce for a one-time interview to discuss my loss experience in more depth.
		yes, my contact information is listed below no, please do not contact me
Name:
Phone:
E-mail:

Thank you so much for participating in this questionnaire. Your experiences will truly be beneficial to other people.