Thanks so much for your interest in a Grief Support Group with us at A Quiet Place Counseling! Please take a moment to complete the survey below to help us create opportunities to support you and others who are navigating through grief and loss.

Please note that your responses will not register you for a grief support group, but will rather assist us during the planning phase of this group. We greatly appreciate your input!

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* 1. Name

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* 2. Age

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* 3. Phone Number

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* 4. Email

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* 5. Would you like to be added to our AQPC Newsletter to receive our latest updates and information about upcoming groups and events, mental health tips, & other free resources to support your well-being?

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* 6. Would you prefer an in-person or virtual group?

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* 7. What would you hope to get from a grief support group?

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* 8. Preferred day(s) of week & time(s) of day for a grief support group?

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* 9. Any questions, comments, and/or ideas for us as we consider ways to best support those who are navigating through grief?

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