Inglés Español

1996 Eastman Ave., Ste. 101
Ventura, CA 93003

Youth Grief Evaluation Form

Welcome to your Minor Grief Evaluation

1. Feeling confused about the death (asking a lot of why questions, disbelief, denial).

2. Feelings of depression (sadness, crying spells, fatigue, isolating).

3. Feeling irritable, angry, frustrated or impatient.

4. Feelings of guilt related to the death

5. Feeling anxious about death of others or self (clingy, overprotective, dependent, worried someone else could die).

6. Feeling nervous or unsafe since the death.

7. Acting younger than age (baby talk, needier, helpless).

8. Difficulty concentrating, following through on a task, completing homework.

9. Experiencing fears and/or phobias since death.

10. Unwilling to accept the loss, denial of the death. Refusal to talk about the death.

11. Experiencing the following physical symptoms since the death: headaches, stomach aches, body pains, etc.

12. Experiencing a loss or increase of appetite since the death. (Disinterested in food or can’t seem to get enough.)

13. Experience sleep disturbances such as inability to sleep through the night, nightmares, bedwetting, sleeping at odd times, fear of sleeping alone.

14. Onset of stuttering.

15. Increase number of accidents, injuries.

16. Increase in risky behaviors (truancy, fighting, alcohol/drug use, staying out late, driving fast, change in peer group).

17. Social withdrawal and disinterest in normal activities. Avoiding friends. (Increase in television watching or gaming.)

18. Problems at school. (Teacher(s) have voiced concerns, doesn’t want to go to school, drop in performance, issues with peer group)>

19. Increase in acting out behaviors (bullying, hitting, tantrums, screaming, aggressive, breaking/throwing things)

20. Problems at home.

21. Defiant, disrespectful, oppositional behavior.