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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