Behavioral Changes - Questionnaire for Kids
Pre-Teen/Teens Questionnaire: Name: ________________________
Death is the biggest change anyone can experience and it affects every part of our lives. After a death, or after the diagnosis of a terminal illness, changes in feelings and/or behaviors are normal. No one will see your answers except the FRIENDS WAY Staff.
How are you related to the deceased? ______________________________________________
How have these areas of your life changed or been affected since the death?
Relationship with your parent(s) _____________________________________________________
______________________________________________________________________________
School/grades/teachers ___________________________________________________________
______________________________________________________________________________
Friendships/social life _____________________________________________________________
______________________________________________________________________________
Sleeping/eating habits _____________________________________________________________
_______________________________________________________________________________
Other family relationships __________________________________________________________
_______________________________________________________________________________
Any other changes ________________________________________________________________
_______________________________________________________________________________
What emotions have you been experiencing since the death (circle all that apply):
shock guilt fear anger shame hopelessness relief sadness anxiety loneliness embarrassment confusion happiness other ________________________________
Since the death have you experienced any physical symptoms (head/stomach aches etc.)? NO YES
If yes, explain ________________________________________________________________________
Are you taking any medications? NO YES (specify what and why) _______________________________
____________________________________________________________________________________
Are you seeing a counselor? NO YES - What brought you to the counselor? __________________________
____________________________________________________________________________________
Who are the supportive people you talk to about the death? _______________________________________
_____________________________________________________________________________________
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