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Hospice Referral
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Colorado Hospice Bereavement Services
*
Indicates required field
Name
*
Name of my loved one
*
Relationship
*
The date my loved one died
*
Everyone's grief journey is different. For each item please select the response that describes your grief experience during the past week.
There are days when I can't believe my loved one is dead.
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Not true
Sometimes true
Very true
I enjoy spending time with other people.
*
Not true
Sometmes true
Very true
I don't know where God is in all this.
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Not true
Sometimes true
Very true
I feel I have influence over what happens to me and my loved ones.
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Not true
Sometimes true
Very true
I cannot think of my loved one without experiencing strong pain.
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Not true
Sometimes true
Very true
My beliefs have been challenged by my recent loss.
*
Not true
Sometimes true
Very true
I can accept the fact that my loved one is dead and not coming back.
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Not true
Sometimes true
Very True
I am not very interested in being with others.
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Not true
Sometimes true
Very true
I have adjusted to day-to-day life without my loved one.
*
Not true
Sometimes true
Very true
I don’t know who I am since my loved one died.
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Not true
Sometimes true
Very true
There are days when it seems like my sadness will ease.
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Not true
Sometimes true
Very true
I am able to find joy in life again.
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Not true
Sometimes true
Very true
I have grown as a result of my grief experience.
*
Not true
Sometimes true
Very true
Right now my life feels out of control.
*
Not true
Sometimes true
Very true
Day-to-day life without my loved one is very difficult.
*
Not true
Sometimes true
Very true
I deeply long for my loved one’s presence.
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Not true
Sometimes true
Very true
I’ve found a way to keep my loved one close in my heart.
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Not true
Sometimes true
Very true
My beliefs give me comfort and strength.
*
Not true
Sometimes true
Very true
I feel abandoned by God.
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Not true
Sometimes true
Very true
I draw comfort from my memories.
*
Not true
Sometimes true
Very True
Comment
*
Thank you for taking the time to fill this out. If you would like to talk to someone, please call Debra Kooser at 303-465-0944.
Remember, all of our services remain open to you.
@Copyright, Colorado Hospice Organization. These materials may only be used with permission.
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