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A unique and mind-blowing 21st Century path to change ...
Attractor Field Therapy
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Grief Relief
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Grief Questionnaire
Your name
*
First
Last
Your email address
*
Enter Email
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1. How long has it been since you lost your loved one?
*
1 = Less than a month
2 = Less than a year
3 = More than a year
2. Have you sought help before for your grief?
*
1 = Family doctor
2 = Mental Health Professional (Therapist, Counselor, Psychiatrist)
3 = Grief Support Group (Church, community, etc)
4 = Friends and Family
5 = More than one of the above
6 = No
3. Have you been prescribed a medication to help with your grief?
*
1 = Yes
2 = No
4. In the past month have you had trouble accepting the death of your loved one?
*
1 = Not at all
2 = Somewhat
3 = A lot
5. In the past month how much have felt yourself longing or yearning for the one you lost?
*
1 = Never or almost never
2 = Once or twice a week
3 = Almost every day
4 = Every day
5 = Several times a day
6. How much you you say your grief still interferes with you life and happiness?
*
1 = Not very much
2 = Somewhat
3 = A lot
4 = I can't or haven't been able to get on with my life since I lost the love one
7. Are you angry or bitter over the loss of your loved one?
*
1 = Yes
2 = No, but I used to be
3 = Never
8. Do you have regrets concerning the one you lost?
1 = I regret things I said or did
2 = I regret things I did not say or things I did not do
3 = I regret both things said and did and things I did not say and/or did not do
4 = No regrets
9. In the past month have you had difficulty connecting with other people?
*
1 = Slight difficulties connecting with people
2 = Some difficulties connecting with people
3 = Great difficulties connecting with people
4 = Almost unable to connect with people
5 = No difficulties in connecting with people
10. Have or do you feel that life is empty and meaningless without the one you lost?
*
1 = I used to but it passed
2 = I still have some feelings that live is empty and meaningless without them
3 = I still have a strong feeling that life is meaningless and empty without them
4 = I still have an extreme sense of emptiness and meaninglessness without them
11. When you picture the one you lost in your mind do you cry or feel a frantic need to see or be with them?
*
1 = Yes
2 = No
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