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Bereavment needs survey
1.
Gender and Age
Male
Female
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)
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)
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)
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.
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)
7.
If there was group support available, would you attend?
Yes
No
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)
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)
10.
What days/times work best for you to attend meetings? (check all that apply)
Week days
Weekend
Evenings
Daytime
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)
Current Progress,
0 of 11 answered
