Prolonged Grief Disorder Assessment Form Template

When supporting individuals through complex bereavement, mental health professionals need structured, compassionate tools to evaluate prolonged grief disorder (PGD) and complicated bereavement. This Prolonged Grief Disorder Assessment Form provides a comprehensive clinical framework for screening, documenting loss timelines, and evaluating functional impairment—all while maintaining the sensitivity required for grief work.

Built for Mental Health Professionals and Grief Specialists

This template is designed specifically for therapists, counselors, psychologists, and bereavement specialists working with clients experiencing intense, persistent grief that interferes with daily functioning. The form captures essential clinical information including:

• Demographic and referral information
• Detailed loss timeline and circumstances
• PGD symptom screening based on DSM-5-TR and ICD-11 criteria
• Functional impairment across life domains
• Risk assessment and safety screening
• Treatment history and current support systems

Why Paperform for Clinical Assessments?

Paperform's flexible form builder lets you create professional, on-brand clinical assessments that feel less like rigid surveys and more like thoughtful intake processes. The doc-style editor makes it easy to add context, instructions, and empathetic language throughout the form, while conditional logic can tailor the assessment based on client responses.

For mental health practices, Paperform offers SOC 2 Type II compliance and secure data handling, giving you confidence that sensitive client information is protected. Please note that Paperform is not HIPAA compliant, so practices requiring HIPAA compliance should evaluate their specific regulatory needs.

Streamline Your Clinical Workflow

Beyond data collection, Paperform integrates with the tools mental health practices already use. Send completed assessments to your EHR system, log them in Google Sheets or Airtable for tracking, or use Stepper (stepper.io) to automate follow-up workflows—like scheduling initial consultations, sending pre-session questionnaires, or routing urgent cases to supervisors for immediate review.

With Papersign (papersign.com), you can seamlessly transition from assessment to consent forms and treatment agreements, keeping all documentation linked to the original intake for a complete clinical record.

Customize for Your Practice

Every grief specialist works differently. This template provides a strong clinical foundation, but you can easily adapt it to match your therapeutic approach, add practice-specific scales, or adjust language to reflect your client population. Whether you work in private practice, hospital settings, hospice care, or community mental health, Paperform gives you the flexibility to create assessments that support your clinical judgment while maintaining professional standards.

Start with this template and deliver more compassionate, efficient bereavement care from the first point of contact.