Self-Assessment Referral Form - East Suffolk

Your full name*

1. I feel able to face the pain which comes with loss

Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree

2. For me, it is difficult to switch off thoughts about the person I have lost

Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree

3. I feel very aware of my inner strength when faced with grief

Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree

4. I believe that I must be brave in the face of loss

Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree

5. I feel that I will always carry the pain of grief with me

Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree

6. For me, it is important to keep my grief under control

Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree

7. Life has less meaning for me after the loss

Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree

8. For me, it’s best to avoid thinking about my loss

Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree

9. It may not always feel like it but I do believe that I will come through this experience of grief

Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree

10. Can you tell us about your bereavement? Tell us about what is most difficult for you? E.g. loneliness, nightmares, low mood

11. Did you witness any particularly distressing events that continue to trouble you?

12. For how long had the person been ill? Have you previously suffered any other significant losses?

13. What helps you to manage at the current time? Do you have support from friends and family?

14. Can you please tell us if you are currently on any medication, or coping with any ongoing mental or physical health issues?

15. Do you have any previous mental or physical health conditions that you would be happy to share with us or may be important for us to know?

16. Are there any other issues, comments or events that you feel it would be helpful for us to know about?

We offer support/counselling via a number of routes. Please tick all options you are interested in:

Telephone
Online (Zoom or Teams)
Face to face - individual
Face to face - group support
Art therapy

For face to face support, which location is best for you? Tick all that apply:

Ipswich
Stowmarket
Felixstowe
Beccles (Mon, Tues, Weds, Thurs)
Gorleston (Tues or Thurs)
Martham (Thurs only)
Lowestoft (Tues only)

The service operates between 9am and 5pm, Monday to Friday. Please let us know your availability and any factors we need to be aware of eg. within school hours, shift patterns*

We are currently assessing if there is a need for online groups. Please select if you would prefer an online group, should this be available:

Yes, I would like online groups to be an option
No, I am not interested

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Self-Assessment Referral Form – East Suffolk

Nearly there – please complete the below self-assessment to complete the referral and our team will be in touch.

If you are a professional completing the referral on behalf of someone else, you can leave this page.

Nearly there – please complete the below self-assessment to complete the referral and our team will be in touch.

If you are a professional completing the referral on behalf of someone else, you can leave this page.

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