--- title: Prolonged Grief Disorder Assessment Form Template | Paperform description: Professional prolonged grief disorder assessment form for mental health professionals. Screen for complicated bereavement, evaluate functional impairment, and document loss timelines with this comprehensive clinical template. url: "https://paperform.co/templates/prolonged-grief-disorder-assessment-form" type: static generatedAt: "2026-04-03T00:49:55.490Z" --- [← Back to free form templates](/templates/) ![Prolonged Grief Disorder Assessment Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/prolonged-grief-disorder-assessment-form.png) [Preview](https://_preview.paperform.co/ai-template/prolonged-grief-disorder-assessment-form) [Use this template for free](/create?ai-template=prolonged-grief-disorder-assessment-form) [Surveys & Questionnaires](/templates/category/surveys/)[Healthcare & Medical Forms](/templates/category/healthcare/) [Healthcare](/templates/industry/healthcare/)[Mental Health](/templates/industry/mental-health/) [Therapist](/templates/role/therapist/)[Counselor](/templates/role/counselor/)[Psychologist](/templates/role/psychologist/)[Social Worker](/templates/role/social-worker/) About this free form template ### 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. Built for growing businesses, trusted by bigger ones. Trusted by 500K+ business owners and creators, and hundreds of millions of respondents. ![Capterra - 4.8 out of 5](/images/capterra-st.jpg) ![Trustpilot - 4.8 out of 5](/images/trustpilot-st.jpg) ![G2 - 4.8 out of 5](/images/g2-st.jpg) [Try Paperform free now](/register) ## More templates like this [![Eating Disorder Screening Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/eating-disorder-screening-form.png) ### Eating Disorder Screening Form A comprehensive eating disorder screening tool featuring the Eating Attitudes Test (EAT-26), body image assessment, and nutritional risk evaluation to identify individuals who may benefit from professional evaluation and support.](/templates/eating-disorder-screening-form/) [![Eating Disorder Screening Tool](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/eating-disorder-screening-tool.png) ### Eating Disorder Screening Tool A comprehensive eating disorder screening form that assesses eating behaviors, body image, nutritional status, and mental health to identify individuals who may benefit from professional support and referral.](/templates/eating-disorder-screening-tool/) [![Acceptance and Commitment Therapy (ACT) Intake Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/acceptance-and-commitment-therapy-act-intake-form.png) ### Acceptance and Commitment Therapy (ACT) Intake Form Comprehensive ACT therapy intake form with psychological flexibility assessment, values clarification exercises, and committed action planning to help therapists understand client needs and therapeutic goals.](/templates/acceptance-and-commitment-therapy-act-intake-form/) [![Addiction Counseling Practice Client Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/addiction-counseling-practice-client-referral-form.png) ### Addiction Counseling Practice Client Referral Form A comprehensive client referral form for addiction counseling practices to collect essential information about potential clients, including addiction type, treatment preferences, insurance details, and group therapy eligibility.](/templates/addiction-counseling-practice-client-referral-form/) [![Addiction Recovery Monitoring & Sobriety Tracker](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/addiction-recovery-monitoring-sobriety-tracker.png) ### Addiction Recovery Monitoring & Sobriety Tracker Track sobriety milestones, identify relapse triggers, and monitor support group attendance for addiction recovery programs. A comprehensive check-in form for patients and counselors.](/templates/addiction-recovery-monitoring-sobriety-tracker/) [![Addiction Screening & Assessment Quiz](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/addiction-screening-assessment-quiz.png) ### Addiction Screening & Assessment Quiz A comprehensive screening tool for substance abuse counselors to assess usage patterns, evaluate life impact, and provide evidence-based treatment recommendations.](/templates/addiction-screening-assessment-quiz/) [![Addiction Treatment Counselor Burnout & Compassion Fatigue Self-Assessment](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/addiction-treatment-counselor-burnout-compassion-fatigue-self-assessment.png) ### Addiction Treatment Counselor Burnout & Compassion Fatigue Self-Assessment A comprehensive self-assessment tool for addiction treatment counselors to evaluate burnout levels, compassion fatigue, secondary trauma, and self-care effectiveness to support professional longevity and wellbeing.](/templates/addiction-treatment-counselor-burnout-compassion-fatigue-self-assessment/) [![Adult Autism Spectrum Evaluation Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/adult-autism-spectrum-evaluation-form.png) ### Adult Autism Spectrum Evaluation Form Comprehensive autism spectrum evaluation for adults, including social communication assessment, sensory profile questionnaire, and developmental history to support diagnostic evaluation.](/templates/adult-autism-spectrum-evaluation-form/) [![Animal-Assisted Therapy Intake Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/animal-assisted-therapy-intake-form.png) ### Animal-Assisted Therapy Intake Form A comprehensive intake form for animal-assisted therapy programs that screens for allergies, assesses comfort with animals, and establishes therapeutic goals for clients seeking healing through animal interaction.](/templates/animal-assisted-therapy-intake-form/) [![Anonymous ACT Fidelity Concern Report](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/anonymous-act-fidelity-concern-report.png) ### Anonymous ACT Fidelity Concern Report A confidential reporting form for submitting concerns about Assertive Community Treatment (ACT) program fidelity, evidence-based practice adherence, and client outcome monitoring.](/templates/anonymous-act-fidelity-concern-report/) [![Anonymous Peer Support Specialist Boundary Violation Report](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/anonymous-peer-support-specialist-boundary-violation-report.png) ### Anonymous Peer Support Specialist Boundary Violation Report A confidential form for reporting boundary violations by peer support specialists, ensuring client safety and adherence to behavioral health certification standards.](/templates/anonymous-peer-support-specialist-boundary-violation-report/) [![Autism Spectrum Screening & Age Verification Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/autism-spectrum-screening-age-verification-form.png) ### Autism Spectrum Screening & Age Verification Form A comprehensive screening form for autism spectrum evaluation that includes age verification, developmental history, school records, and appointment scheduling for professional assessment.](/templates/autism-spectrum-screening-age-verification-form/)