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Early Grief Support & Understanding

Thank you for being here. We know that reaching out during early grief can take courage, especially when everything feels uncertain.

This form helps Airlie Days understand how people experience early grief, so we can offer thoughtful, gentle support and continue building services that truly meet people where they are.

Alongside gathering understanding, we are running a small pilot programme to support a limited number of people, focusing on building coping tools and healthier ways of living alongside grief.

You’re welcome to skip any question. Your responses will be treated with care and confidentiality.

This form takes around 5–7 minutes.

I consent to Airlie Days storing my responses securely and contacting me by email about support or the pilot programme.

I consent to Airlie Days storing my responses securely and contacting me by email about support or the pilot programme.

Email (Required)

Preferred name

Please note: Airlie Days is not a crisis service and cannot provide immediate support. If you feel unsafe or in crisis right now, please get in touch with emergency services or Samaritans on 116 123.

Age

Age

Gender (Optional)

Gender (Optional)

Location/City/Postcode

Relationship Status

Relationship Status

Employment Status

Employment Status

What industries have you worked in?

When did your loss happen?

When did your loss happen?

Who did you lose?

Who did you lose?

If you’d like, you can tell us a little more about this person:

Have you experienced more than one significant loss?

Have you experienced more than one significant loss?

Would you like to briefly tell us about the other loss or losses? (optional)

Do you currently have, or have you previously had, any diagnosed mental or physical health conditions you feel are relevant?

On a scale of 0–10, how supported do you currently feel?
(0 = not supported at all, 10 = very supported)

On a scale of 0–10, how supported do you currently feel?(0 = not supported at all, 10 = very supported)

On a scale of 0–10, how manageable does day-to-day life feel right now?
(0 = not manageable, 10 = manageable)

On a scale of 0–10, how manageable does day-to-day life feel right now?(0 = not manageable, 10 = manageable)

On a scale of 0–10, how connected do you feel to other people?
(0 = completely disconnected, 10 = well connected)

On a scale of 0–10, how connected do you feel to other people?(0 = completely disconnected, 10 = well connected)

Which of these best describes how things feel at the moment?

Which of these best describes how things feel at the moment?

If you would like, tell us in your own words what feels most worrying or heavy right now:

What would be helpful right now?

What would be helpful right now?

What type of support would you be open to?

What type of support would you be open to?

Are you open to virtual support (video or phone)?

Are you open to virtual support (video or phone)?
A
B
C

Would you like to be contacted about Airlie Days pilot support (if eligible)

Would you like to be contacted about Airlie Days pilot support (if eligible)
A
B
If you are eligible for the pilot and choose to hear from us, we will review your answers and respond within 48 hours. If we are unable to offer support right now, we will signpost other services.