CHILD LIFE GRIEF/BEREAVEMENT REFERRAL

PATIENT NAME [Patient Name] ROOM # [ROOM #] AGE [age] DATE [date | time]
FIRST NAME ______________________________ LAST NAME _____________________________________________
AGE ___________ GENDER _______________________
RELATIONSHIP TO PATIENT [Comments] PREFERRED LANGUAGE [Comments]
MODE OF CONTACT [Comments] REASON FOR REFERRAL [Comments]

PHYSICAL EMOTIONAL SOCIAL SPIRITUAL

No changes  No changes  No changes  No changes 
Changes in: Guilt  Lack of fam. support  Has spiritual support 
Appetite  Depression  Isolation  No spiritual support 
Health  Anger  Lack of activities  Exhibits faith 
Sleeping Habits  Loneliness  Supportive friends  Questions faith 
Appearance  Thoughts of suicide  Change in academic status/  Not Applicable 
Energy level  Anxious/distraught  attendance
[Other]  Denies/Represses feelings  [Other] 
Inadequate coping
Expresses feelings Notes:
Adequate coping __________________________________________________
__________________________________________________
__________________________________________________
__________________

INTERVENTIONS ADDITIONAL NOTES/COMMENTS:

 Treatment Support __________________________________________________________________
__________________________________________________________________
 Visit Preparation
__________________________________________________________________
 Medical Play __________________________________________________________________
 Bibliotherapy __________________________________________________________________
__________________________________________________________________
 Family Support/Education
__________________________________________________________________
 Legacy Activities _____________________________________________________________
 Life & Death Education
 Other: _______________________

OTHER RECOMMENDATIONS/OUTSIDE REFERRALS

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

ITEMS/MEASURES PROVIDED [Comments]

FOLLOW-UP [Follow-up] | NEXT MEETING [date | time]

UC SAN DIEGO HEALTH