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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