Loss of Intimacy Grief Survey for Survivors
Thank you for participating in this project. I am researching the experiences of those who have had a partner die. Your answers will be anonymous, and your information will be protected. I am a grief therapist and I do grief education for both professionals and the public.

I am doing a companion survey of therapists and hospice staff as well. The goal is to look at how well intimate partners needs are being met during a terminal illness and afterward. Loss if sexual intimacy typically has a significant impact during that time. I would like to gather enough data to support teaching professionals that they have a role in proactively addressing loss of sexuality for both the patient and the intimate partner.

The survey is 13 short questions, with space at the end for any additional comments you may want to add. Should you need any additional support following the survey you can reach me by email at jill@centralcounselingservices.net.

Thank you for helping with this project.

1. Did your spouse’s illness change your sexual intimacy?
2. Did you feel a sense of loss with their illness in regard to your sexual intimacy?
3. Did your spouse’s medical providers initiate any discussion about the loss of sexual intimacy because of the illness or medications?
4. Did you initiate any discussion with your spouse’s medical providers about the loss of sexual intimacy?
5. Did anyone caring for your spouse medically offer ideas to continue your sexual intimacy as a couple that could be adapted to the realities of the illness?
6. Did any medical providers caring for your spouse offer ideas regarding adapting your sexual relationship to the limitations caused by their illness?
7. If your spouse was under the care of hospice, did any member of the team bring up the topic of sexual intimacy with your spouse?
8. If your spouse was under hospice, did any member of the team bring up the topic of the loss of sexual intimacy with you, and how to manage that through adaptation?
9. Did the loss of sexual intimacy impact the quality of life for you and your spouse?
10. Has anyone providing grief support for you brought up the topic of the loss of your sexual relationship with your spouse as a significant loss?
11. Would it be helpful in your healing to be able to talk about that loss?
12. Would you be comfortable bringing up that subject with a therapist or grief provider if they have not?
13. Which, if any of these, is causing you to not bring up the loss of sexuality with a grief provider or therapist?
14. Do you have any other thoughts you might want to share about this topic?
Your answer
Thank you for your willingness to share your experiences and thoughts. The results can be made available to you. My hope is that we can start a new conversation about an aspect of terminal illness and grief that is rarely acknowledged. If this has brought up issues for you please do not hesitate to contact me via email and I will provide resources for you. You can also locate a grief therapist through your insurance or through online search programs, such as Psychology Today or Good Therapy
Submit
Never submit passwords through Google Forms.
This form was created inside of Central Counseling Services, Inc. Report Abuse - Terms of Service