Please enable JavaScript in your browser to complete this form.Name *FirstLastDate / TimeDateTimePlease rate your current level of DistressLevel of Emotional Distress Selected Value: 0 1 = Low Ability 7 = High AbilityLevel of Spiritual Distress Selected Value: 0 1 = Low Ability 7 = High AbilityPlease rate your current ability to:Cope with your emotional distress Selected Value: 0 1 = Low Ability 7 = High AbilityFunction in your every day life Selected Value: 0 1 = Low Ability 7 = High AbilityPlease rate your current knowledge of the following:Your knowledge of the grief process Selected Value: 0 1 = No Knowledge 7 = A Lot of KnowledgeYour knowledge of grief coping strategies Selected Value: 0 1 = No Knowledge 7 = A Lot of KnowledgeYour knowledge of stress management strategies Selected Value: 0 1 = No Knowledge 7 = A Lot of KnowledgeYour knowledge of community resources Selected Value: 0 1 = No Knowledge 7 = A Lot of KnowledgeWebsiteSubmit