Bereavement Support Services Evaluation (CB)

1. Bereavement mailings provided helpful information and support.*

1a. The amount of bereavement mailings received was:*

2. After the death of your loved one, did you receive telephone calls from the bereavement program?*

2a. The number of bereavement telephone calls I received was:*

2b. Overall, how helpful was the telephone support you received from the bereavement program?*

3. After the death of your loved one, did you call the bereavement program for information or support?*

3a. A counselor followed up with me in a timely manner.*

3b. Overall, how helpful was the telephone support you received from the bereavement program?*

4. After the death of your loved one, did you meet with a counselor from the bereavement program either in person or virtually?*

4a. How helpful was the individual counseling support?*

5. After the death of your loved one, did you attend any support groups or educational programs provided by the Hospice bereavement program?*

5a. How helpful were the grief groups or programs you attended?*

4/5a. If you did not use any bereavement support options other than mailings, please explain why. (select one)*

6. Grief support services were provided in a culturally sensitive manner.*

6a. Please explain:*

7. Overall, how well did the bereavement services meet your needs after the death?*

8. How could our bereavement support services be improved?

9. Is there anything else you would like to share about our bereavement services?

10. Would you like someone from the bereavement program to follow up with you?*

Name*

First Last

Phone*

Best time to reach you:*