checked /> Patient has dependent family members checked /> Patient does not have dependent family members checked /> Patient Family/Caregiver does not have other important Relationships checked /> Patient Family/Caregiver has other important Relationships checked /> Patient Family/Caregiver predicted coping is POOR checked /> Patient Family/Caregiver predicted coping is Good checked /> Patient Death will result in Financial Hardship checked /> Patient Death will not result in Financial Hardship checked /> Patient Family does not have Previous Experience dealing with loss checked /> Patient Family has Previous Experience dealing with loss checked /> Patient Family has History of Alcohol/Drug abuse checked /> Patient Family does not have History of Alcohol/Drug abuse checked /> Patient Family has History of Physical/Emotional abuse checked /> Patient Family does not have History Physical/Emotional abuse checked /> Patient Family is not involved with Care of Patient checked /> Patient Family is involved with Care of Patient checked /> Patient Death is not Prepared for checked /> Patient Death is Prepared for checked /> Other

checked /> Spiritual Questioning checked /> Recent Loss/Grief checked /> Patient is Suicidal checked /> Patient is Depressed checked /> Patient is Angry checked /> Patient has Shame checked /> Patient has Guilt checked /> Isolation/Withdrawal checked /> Feelings of Abandonment checked /> Expresses Unfinished Business checked /> Concern with Death and Dying checked /> Other