Bereavment needs survey Question Title * 1. Gender and Age Male Female OK Question Title * 2. Have you personally experienced a loss? If YES please see Question # 3 if NO please move to question #4 No Yes– how long ago? In the last 12 Months In the last 5 years In the last 10 years 10+ years Other (please specify) OK Question Title * 3. Please indicate your relationship with the person who died. (check all that apply) Parent/ Step Partner/spouse Grandparent Child Brother/Sister Other Other (please specify) OK Question Title * 4. What would you find most valuable when looking for Grief Support One on one with a bereavement counselor Group setting with others who have experienced loss Online Material Volunteer Support (1 on 1 with a trained volunteer) Other (please specify) OK Question Title * 5. Have you ever received grief support or attended a grief support group in the past? If you answer is no (please list reasons you chose not to or couldn’t attend) Yes - a support group Yes - one on one support Yes - I have received support but outside of Haliburton County No- I have not received any supports If you answered no do you have reasons why you did not choose support? Please describe. OK Question Title * 6. If you were to attend a Bereavement Support Group, what would you hope to gain? (Check all that apply) A safe place to share Compassionate listening Education about grief and loss Healing Knowing I am not alone Other (please specify) OK Question Title * 7. If there was group support available, would you attend? Yes No OK Question Title * 8. If answer to # 7 was "No" Please specify why Lack of transportation Don't feel comfortable in groups Concerned about confidentiality Concerned about being judged Have limited time Other (please specify) OK Question Title * 9. If you were interested in attending a support group, what type of offering might in terest you? (Check all that apply) Weekly (1-2 hours) Every other week (1-2 hours) Monthly (2-3 hours) Half day workshop (4 hours) Whole day workshop (8 hours) On going Time limited (6 weeks, for example) Other (please specify) OK Question Title * 10. What days/times work best for you to attend meetings? (check all that apply) Week days Weekend Evenings Daytime OK Question Title * 11. What other services might be valuable or helpful to you? (Check all that apply) Books DVDs One on one Support Online support Referrals to other services (such as spiritual support, counseling, crisis intervention, hospice volunteer, etc.) Other (please specify) OK DONE