Grief Experience Check-In | Personal Reflection Results

Mosaic Clinic · Grief & Loss

Grief Experience Check-In

An optional, private questionnaire for noticing how grief has affected your emotions, daily life, and relationships during the past month.

There are no right answers, no required timetable, and no expectation to feel a particular way.

Not a diagnostic test. This original Mosaic Clinic inventory is not the copyrighted PG-13 and has not been clinically validated. Results identify experiences to discuss with a professional; they cannot determine whether you have prolonged grief disorder (PGD).

Before you begin

The questions below are intended for grief following a death. Grief after other losses deserves support too, but this specific inventory may not fit those circumstances.

Privacy: This questionnaire calculates a summary in your browser. The answers are not submitted to Mosaic Clinic or saved to an account. You can print your results for yourself or share them with your clinician if you choose. Please complete it on a device you trust.

About your grief


You do not need to enter names or identifying information.

A. Connection and longing

During the past month, how much has each experience affected you?

1 There are moments when the wish to be with or speak to the person who died feels especially powerful.
2 Thoughts about the person or what happened take up so much attention that other activities become difficult.
3 I find myself expecting the person to be present, even while knowing that they have died.
4 Some places, possessions, or routines are difficult to approach because they make the loss feel immediate.
5 Memories or reminders bring intense waves of sorrow, anger, or other painful feelings.
6 The reality of the death is difficult for me to absorb or make sense of.

B. Identity, emotions, and daily life

Use the same 0–4 response scale.

7 Who I am, what matters to me, or my place in the world feels changed or unclear since the loss.
8 I feel disconnected from my emotions or from the people around me.
9 I have difficulty trusting others, reaching out, or feeling supported.
10 I feel stuck between remembering the person and participating in everyday life.
11 The future seems hard to imagine or lacks a sense of possibility.
12 The absence of this person has left me feeling unusually isolated or alone.

C. Impact and context

13. How much is grief affecting everyday functioning (work, school, caregiving, relationships, self-care, or sleep)?
14. Does your grief feel different from what your family, culture, or community expects or supports?

You can skip any item. The results will note how many questions you answered.

Adapted into an original reflection tool for Mosaic Clinic; not the PG-13, not a standardized measure, and not suitable for a numerical diagnostic cutoff. To learn about validated instruments, visit Weill Cornell’s Center for Research on End-of-Life Care.

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