Intake form
Health Promotion and Education 3190
Death and Dying
Name_________________________________________________________________________
Current work or career history
_____________________________________________________________________________
Experiences with death and dying
______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________
What other classes are you taking? How many credits?______________________________________ ______________________________________________________________________________
______________________________________________________________________________
What are your college and career goals?________________________________________________ ______________________________________________________________________________
Why are you taking this course?______________________________________________________ ______________________________________________________________________________
______________________________________________________________________________
What are some of your FEARS in taking this course?What are some of your GOALS in taking this course?List a couple of the greatest challenges you have faced or are currently facing.What is the number one goal in your life?
What is it you want to take away from this course?What types of learning techniques do you find most helpful (i.e., videos, lecture, guest speakers, group work, role-play, homework, take home exercises, in-class exercises)?What have instructors done in the past that you have really enjoyed? How can I make this class more enjoyable and helpful for you?What do you expect and want from your instructor/facilitator?Intake Assessment
Name___________________________ Date _____________________
The purpose of this assessment is to provide the instructor with some personal background on you and on your thoughts, values, perceptions, and experiences regarding death and dying. Though this information will be kept confidential, your responses and questions will be considered when developing course content. Your candor is appreciated and valued. It helps in tailoring a meaningful class for YOU and for the rest of the class. You are free to not respond to any question.
At what age and in what year do you expect to die? What do you suspect your cause of death might be?
Do you have a legal will, advanced directives, or organ donor card? Explain.
Do you have any ethical considerations regarding suicide, euthanasia, abortion, life-threatening support practices, or the death penalty? Explain.
Do you have any risk-taking behaviors (smoking, drinking, drugs, unsafe sex, etc.)? Do you engage in any life-endangering behaviors? Explain.
Have you ever been on medication for emotional problems, been to or are currently seeing a psychotherapist, or hospitalized for mental illness? Explain.
Have you ever attempted suicide or had suicidal thoughts? Explain when this was, what the circumstances were, and if you still harbor these thoughts.
How do you want your body disposed of when you die (entombment, cremation, burial, cryonics)? Describe some of your funeral wishes.
Is there a time in life when you consider someone's death as being “too early to die?” When is that? Explain.
What are some of the considerations you have provided when someone you knew and loved died (flowers, card, food, etc)? Explain.
What are your thoughts about an afterlife?
What does the “good death” mean to you?
What is your earliest memory of death?
Who has died in your family? What were their ages and your age at the time they died? What were the causes of these deaths?
When was the most recent death you experienced? Discuss the experience.
What non-death losses have you experienced (loss of job, loss of home, divorce or romance breakup, loss of a friendship, loss of financial security, etc.)?
What other questions concerning death, dying, bereavement, grief, or losses in general do you have?