Bridges - Adult - Ranken Jordan Pediatric Bridge Hospital

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Bridges For Adults Registration Form

First Name

Last Name

Cellphone / Telephone Number

Email

Nature of Loss

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Relationship to person that died (if applicable)

Check any behaviors you’ve noticed since the death(s):

New fears (the dark, hospitals, etc.) Nightmares Difficulty sleeping Over sleeping Regression (baby talk, bed wetting)Improved school grades Lowered school grades Difficulty concentrating Repeated illnesses Overeating/undereatingSeparation anxiety from caregivers/loved ones Overprotective behavior towards others Withdrawal from family/friendsIncreased arguing Physical fighting Other

If "other" selected, please describe:

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Check any feelings you have noticed since the death(s):

AngerWorrySadnessAnxietyDisappointmentFrustrationApathyConfusionReliefShockHappinessContentmentIrritationAggressionDiscouragementExcitementLonelinessOverwhelmedPlayfulnessOther

If "other" selected, please describe:

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Have you ever participated in a grief group before?

How did you hear about grief group?

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