Complicated Bereavement Disorder Intake Form

Comprehensive Assessment for Complicated Bereavement Disorder

When clients experience prolonged, intense grief that interferes with daily functioning, a structured intake form helps mental health professionals gather the clinical information needed to provide compassionate, evidence-based care. This Complicated Bereavement Disorder Intake Form template is designed for therapists, counselors, and mental health clinicians working with individuals struggling to process significant loss.

Complicated grief—also known as prolonged grief disorder or complicated bereavement disorder—goes beyond typical mourning. Clients may experience persistent yearning, difficulty accepting the loss, identity disruption, avoidance of reminders, or intense emotional pain that doesn't ease with time. This intake form captures the nuanced symptoms and personal context needed for accurate assessment and treatment planning.

Built for mental health professionals who need more than basic intake

Whether you're a grief counselor, psychologist, clinical social worker, or licensed therapist, this template helps you:

• Gather comprehensive loss history including relationship to the deceased, circumstances of death, and time since loss
• Assess core bereavement symptoms like persistent yearning, preoccupation, identity confusion, and difficulty moving forward
• Screen for meaning-making difficulties and existential distress that often accompany complicated grief
• Identify functional impairment across social, occupational, and self-care domains
• Document previous mental health history and current support systems

The form uses conditional logic to ask relevant follow-up questions based on client responses, creating a personalized assessment experience while ensuring you capture all clinically significant information.

Streamline your practice with Paperform + Stepper

Paperform makes it easy to collect sensitive intake information securely and compassionately. The form is fully customizable to match your practice branding, can be completed remotely before the first session, and automatically organizes client data for easy review.

Take your workflow further with Stepper—your AI-native automation tool. Connect this intake form to your practice management system, automatically schedule follow-up appointments, send intake summaries to your secure notes system, or trigger welcome email sequences. Stepper keeps your administrative tasks synchronized while you focus on providing therapeutic support.

For consent forms, treatment agreements, or release of information documents, Papersign lets you send secure eSignature requests directly from form submissions, keeping all client documentation organized and legally compliant.

HIPAA Considerations

Please note that while Paperform is SOC 2 Type II compliant and offers robust security features, it is not currently a HIPAA-compliant solution. For practices requiring HIPAA compliance, please ensure you have appropriate Business Associate Agreements in place with all tools in your workflow, or consult with your compliance advisor about using this template in your specific context.

This template is trusted by grief counselors, bereavement specialists, and mental health practices seeking a compassionate, thorough approach to complicated grief assessment.