* 1. Gender and Age

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

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

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

* 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)

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

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

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

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

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

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

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