Reproductive Loss Care Intake Form
Reproductive Loss Care Intake Form
For use by Soundview's Social Work staff
Full Name
*
Date
Date
*
/
MM
/
DD
YYYY
Marital Status:
Marital Status:
Married
Single
Engaged
Divorced
Widowed
Other
Other
Occupation/Student Status
How many pregnancies has client experienced and what were their outcomes?
*
What is client's reason for seeking Reproductive Loss Care?
*
Relevant details pertaining to client's loss(es)--age at time of loss, relationship status, spiritual beliefs, support received, etc.
Has client ever shared their loss experience(s) with anyone? If so, what was the response?
What physical, emotional/psychological and/or spiritual impact has client's loss(es) had?
What, if any, spiritual beliefs does client currently have?
Is client receptive to a faith-based or bible study program?
*
Is client receptive to a faith-based or bible study program?
Yes
No
Other
Other
What are client's beliefs about forgiveness? (Post-Abortive clients ONLY)
Detail any mental health concerns or substance misuse. Has client every received treatment for these issues? Does client have a history or suicidal ideation or self-harming behavior? (Advise client that this information ensures that they receive the most appropriate recommendations/referrals.)
Social Worker Recommendation
Based upon the information gathered, is client appropriate for participation in Soundview's Reproductive Loss Care program? Provide explanation.
Indicate client's program preference:
Indicate client's program preference:
Individual coaching
Group coaching
Joy Comes in the Mourning Group
Name of Staff Person Completing Intake