Intake form for processing loss after a lost relationship
For the purpose of gaining
insights for yourself: (notebook)
(Only fill in what is
valuable to you, it is about insights)
Name
Address
City
Telephone
E-mail address:
Date of birth
WHAT IS YOUR REQUEST FOR HELP
What happened, who did you separate from?
What caused this separation?
What preceded to this separation?
What happened afterwards?
How did you say goodbye?
How long ago did the loss occur?
How long was the relationship with your partner, parent,
child?
Do you have experience with previous losses?
If so, did you process them? When and how
Personal functioning:
Self-image
Self-esteem
Future perspective
Philosophy of life (practicing)
Health:
Physical complaints
Illness
Use of medication
Psychological problems
Deep emotional pain
Listless, no interest in anything
Unable to resume daily activities
as before
Are you sleeping well
Have you ever thought about
suicide
Addiction (alcohol, tobacco,
drugs, medication)
How are your relationships with your:
Ex-partner
Children
Parents
Friends
Other contacts
Do you have social support, a
good supportive network around you
Living situation:
With whom
How is the division of tasks
Activities:
Paid work
Unpaid work
Care tasks
Household tasks
Free time
Hobbies
Are you a member of an association, or more
What have you done so far to process your loss? (self and assistance)
Organizations:
Contacts with social care institutions
Other organizations
Material circumstances:
Financial
Housing
Training / highest level of education
Are there any other issues?
Practical information:
Costs
Time
Duration
Dates
APPOINTMENT with yourself:
Preference weekly or biweekly work on yourself
Individual / group
What do you expect from a group
What do you decide about participation:
What does the supervisor decide about participation:
DATE:
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