Gender and Age

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* 1. Gender and Age

Have you personally experienced a loss? If YES please see Question # 3 if NO please move to question #4

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* 2. Have you personally experienced a loss? If YES please see Question # 3 if NO please move to question #4

Please indicate your relationship with the person who died. (check all that apply)

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* 3. Please indicate your relationship with the person who died. (check all that apply)

What would you find most valuable when looking for Grief Support

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* 4. What would you find most valuable when looking for Grief Support

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)

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* 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)

If you were to attend a Bereavement Support Group, what would you hope to gain? (Check all that apply)

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* 6. If you were to attend a Bereavement Support Group, what would you hope to gain? (Check all that apply)

If there was group support available, would you attend?

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* 7. If there was group support available, would you attend?

If answer to # 7 was "No" Please specify why

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* 8. If answer to # 7 was "No" Please specify why

If you were interested in attending a support group, what type of offering might in terest you? (Check all that apply)

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* 9. If you were interested in attending a support group, what type of offering might in terest you? (Check all that apply)

What days/times work best for you to attend meetings? (check all that apply)

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* 10. What days/times work best for you to attend meetings? (check all that apply)

What other services might be valuable or helpful to you? (Check all that apply)

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* 11. What other services might be valuable or helpful to you? (Check all that apply)

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