Assessment Questionnaire Step 1 of 8 - Introduction 0% Your email will be required at the end of this assessment in order to send your results.Are you widowed?* Yes No What was your relationship to the person you are grieving?* Child Parent Sibling Friend How old are you now?* How old were you when your spouse or partner died?* How long ago was your spouse or partner’s death?*0-3 months (up to 89 days)3-6 months (90 to 179 days)6 -9 months (180 to 209 days)9 months to a year (210 to 364 days)1 year to 1 year 6 months1 year 6 months to 2 years2 years to 2 years and 6 months2 years and 6 months to 3 years3 years-up to 4 years4 years-up to 5 years5 years- up to 6 years6 years-up to 7 years7 years-up to 8 years8 years-up to 9 years9 years-up to 10 years10 years or moreI identify as* Female Male Transgender Gender nonconforming What is your race?*Please choose one or more White Hispanic Black or African-American Asian Native Hawaiian or other Pacific Islander American Indian or Alaska Native Which of these terms BEST describes your relationship?*(Your relationship with your deceased partner or spouse) Married Engaged In a committed relationship (not married and not engaged) Divorced How long was your marriage or relationship if not married?* 1-6 months 6 months to 1 year 1-2 year 2-3 years 3-4 years 4-5 years 5-6 years 6-7 years more than 7 years How long were you in a committed relationship?*(including any and all - dating + engaged + married) This is to capture your years together rather than restricting it to only the time you might have been legally married. 1-6 months 6 months to 1 year 1-2 years 2-3 years 3-4 years 4-5 years 5-6 years 6-7 years more than 7 years Are you currently married, remarried, or in another committed relationship?* Yes - Married or Remarried Yes - in a committed relationship (not remarried) No - neither remarried nor in a committed relationship Do you have children from your relationship with your spouse or partner?* Yes No Do you have children living at home?* Yes No How did your person die?* Sudden – within 24 hours of knowing there was a illness or issue (other than violence or suicide) Sudden - By violence (an act committed by another person, such as during a robbery) or suicide Less than 6 months after knowing there was an illness or issue More than 6 months after knowing there was an illness or issue Suicide Other Was your spouse or partner in the military?* Yes No Was your spouse or partner a first responder?* Yes No Agency, Identity and Sense of SelfI can face my problems head-on instead of ignoring them*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI trust my gut*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI can make a decision and follow through*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI don't let others' expectations determine how I grieve*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI feel confident I can learn how to do things my partner used to do*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI have a strong sense of who I am, independent of my late partner*Strongly disagreeDisagreeNeutralAgreeStrongly agree Social SupportI have a fulfilling social life*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI belong to a strong supportive community*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI can find support for the things I need*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI am comfortable asking for help when I need it*Strongly disagreeDisagreeNeutralAgreeStrongly agree Living in the MomentI can have fun in the moment*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI can find humor in life*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI find there are times when I can live in the moment*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI laugh at least once every day*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI can feel joy for others when something good happens to them*Strongly disagreeDisagreeNeutralAgreeStrongly agree Helping othersI am caring and compassionate*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI use my experience to help others*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI can sit with someone else in pain*Strongly disagreeDisagreeNeutralAgreeStrongly agree IntegrationI have integrated the love of my late partner with my current life and relationships*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI have found ways to honor my deceased partner or spouse*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI have blended my past life with my present life*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI have created a new life that honors the past*Strongly disagreeDisagreeNeutralAgreeStrongly agree Goals & GrowthI can picture a positive and happy future*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI have goals I am working toward*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI like the person I am now*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI feel stronger because of what I've overcome*Strongly disagreeDisagreeNeutralAgreeStrongly agree You are one step away from completing the assessment. 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