Kids Questionnaire: Red Group



Questionnaire Name: ____________________________

Death changes everything about your life. It helps us to know what you have noticed about yourself since the death. Read the statement then circle the best answer. No one will see your answers except the FRIENDS WAY Staff.

The person/people who died was/were my (circle the ones that apply):

Mother Father Brother Sister Friend Other (who?) ________________

Please circle one answer:

Since the death I want to be by myself: MORE SAME LESS

Since the death, school has been: WORSE SAME BETTER

Since the death I get along with my friends: WORSE SAME BETTER

Since the death I get along with my family: WORSE SAME BETTER

I sleep: MORE SAME LESS

I eat: MORE SAME LESS

I get mad: MORE SAME LESS

I get scared: MORE SAME LESS

I worry: MORE SAME LESS

Since the death I get aches and pains: MORE SAME LESS

I feel happy: YES NO SOMETIMES

How are you feeling right now? (circle as many as you like – or draw another picture of how you feel on the back)

Angry Sad Happy Scared

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