kwestionariusz do konsultacji - Dom Ukojenia | Grief House Warsaw

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1Information about you

2Accessibility and your needs

First name *

Enter your name

E-mail *

Enter your email address so we can send you details of the meeting

Are you an adult? *

Currently, Serenity House activities are for adults. In the future, the House of Serenity will also cater for young people, but at the moment meetings for under-18s do not take place.

What language are you most comfortable speaking? *

in Polish
українською мовою
in English

Select the language in which you are most comfortable communicating

What kind of loss have you experienced? *

death of partner
death of a child
death of another close family member
death of a friend / unrelated person important to me
death of a loved one by suicide
multiple loss (death of a loved one in a short period of time)
perinatal loss
loss of a companion animal
loss of health (of oneself or a loved one)
loss of job/important life role
loss of place (e.g. emigration, forced removal, exile)
other

What type of loss does your application relate to? You may have experienced multiple losses. Choose the loss or aspect of loss that is most difficult for you right now. If your loss is not on the list, please add it.

When did this loss occur (approximately)? *

1 to 5 months ago
6 months to 1 year ago
1-2 years ago
over 2 years ago
I am expecting a loss (a loved one is seriously ill/dying)

Indicate approximately how much time has passed since the loss

What do you need most right now? *

feeling that I am not alone in my grief
opportunities to talk to people who are going through something similar
the opportunity to be among people to whom I do not have to explain myself
joint activities
inspiration on how to look after yourself while you are grieving
knowing how to support others in bereavement
other

You can choose more than one answer

Do you want to write in a few sentences what story you are coming with? (optional)

If you wish, you can write more about your situation

Your current situation

The following questions can be difficult, but they are important. We don't judge your answers - they help us make sure this form of support is enough for you at this time.

Are you currently receiving specialist assistance? *

I do not currently use
I am in individual/group therapy
I use a psychiatrist
I am in therapy and under the care of a psychiatrist
I use another form of assistance

The use of specialist support does not affect your ability to attend Serenity House meetings. This point tells us if you have other resources besides our meetings that you can use.

In the last 2 weeks, have you had thoughts like „I can't live like this”? *

very often (almost every day)
sometimes (several times a week)
rarely
at all

Do you happen to think that you might take your own life in the near future? *

yes
not
I don't want to answer

Thank you for responding/responding so honestly. Your answers are a very important signal.

House of Serenity meetings are community support, not crisis intervention - therefore at the moment we cannot sign you up. This does not mean you are alone_. You need more direct support now.

You can take advantage of the 24-hour, free assistance:

Direct support for people in mental health crisis 800 70 2222
Helpline for children and young people 116 111
Bereavement support from the Suddenly Alone Foundation 800 108 108 (Mon-Fri, 14:00-20:00)

Accessibility and your needs

We want House of Serenity meetings to be as accessible and friendly as possible. The questions below are entirely voluntary - answer the ones that are important to you.

What is important to you in terms of space and movement?

I need an entrance without stairs / with lift
a seat with a backrest is important to me
I have no particular needs in this area
other (may be added at the end of the questionnaire)

Do you need a particular way of communicating?

translation into ukrainian
English translation
Translation into Polish Sign Language
sound reinforcement (induction loop)
I have no particular needs in this area

You can tick more than one answer

Caring responsibilities

I need information on whether I can come with my child to a specific meeting
I need information on whether I can come with my pet to a specific meeting

Are there other important needs that it would be good for us to know about before the meeting?

It is not always possible for us to meet all needs, but we will try our best to accommodate the space and the way meetings are run.

Consents and rules

akceptujesz? zgadzasz przed

Have you read and accept the rules of the House of Serenity meetings? *

yes, I know the rules and agree to abide by them

The rules are available at the bottom of the page https://griefhouse.community/nasze-spotkania/

I understand the meetings of the House of Serenity: *

are a space for social support rather than psychotherapy
do not replace medical assistance or crisis intervention
if necessary, the organisers can offer me a different path of support than participation in the group

Do you consent to the processing of your personal data for the purpose of contacting you and signing you up for your chosen appointment? *

Have you read and accepted the privacy policy? *