Mito Support Group Survey Question Title * 1. Please provide your contact details ... Name: City/Town: State/Province: ZIP/Postal Code: Email Address: Phone Number: Question Title * 2. What is your relationship with mitochondrial disease (mito)? I have mito My partner/spouse has mito My child has mito My parent has mito My sibling has mito My grandchild has mito Another family member has mito My friend has mito My colleague has mito My student has mito I am a medical specialist I am a researcher Other (please specify) Question Title * 3. When are you available to meet?(select as many as appropriate) Weekday during the day Weekday evening Saturday daytime Saturday evening Sunday daytime Sunday evening Question Title * 4. What meeting format/forum suits you?(select as many as appropriate) Informal gathering in a public space (e.g. cafe, restaurant) Meeting in a community centre (e.g. library meeting room, office meeting room) Meeting at a volunteer's home BBQ in a public place (e.g. park) Picnic in a public place (e.g. park) Other (please specify) Question Title * 5. What topics would you most like to discuss at support group meetings? Question Title * 6. What location would you like the meeting to be held (state, city/suburb)? Question Title * 7. Would you be willing to host/facilitate a support group meeting? Yes No Maybe Question Title * 8. Please add any other suggestions/comments for mito support group meetings? Done
