Grief supports survey

Demographics

Age ________

Gender

State

Loss profile

I am grieving because I have lost: a) my partner/spouse b) a child c) a sibling d) a parent e) a

friend f) other ________________

This loss occurred a) less than 6 months ago b) more than 6 months ago

My loss makes these things difficult for me:

1) ____________________________________
2) ____________________________________
3) ____________________________________
4) ____________________________________
5) ____________________________________

Tools

I have used the following to help with my grief:

 Conversations with friends/family

 Volunteer work

Please describe _____________________________________

 Hobbies

Please describe _____________________________________

 Peer support groups

If yes, how often do you attend these groups?

 Individual or group therapy

If yes, how often do you attend therapy?

 Online social network sites or apps

 If yes, name the websites/apps you have used:

________________________________________________________________________

How often do you use them?

 Other

Please describe _________________________________________________

I wish the tools (above) had these types of supports for me:

____________________________________

____________________________________

To help me cope during grief, I would like an online app to provide:

____________________________________

____________________________________

____________________________________

____________________________________