Parkinson's Support Group Survey

Please complete this form if you are interested in joining a Parkinson’s Support Group. The charge for the program is $36 and will include 3 support sessions — no more than 12 participants will be in any group. Mental health providers will facilitate the groups. (Future group sessions will be determined by the interest of the group members following the first 3 sessions). Please complete this form as soon as possible so that we can schedule sessions and send the actual registration/payment form.

SPIRIT: Parkinson's Support Group Interest Form

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Capacity(Required)

PWP (Person with Parkinson's)

Carepartner

Availability (check as many as are applicable)(Required)

Weekdays (EST)

Weeknights (EST)

Sunday morning (EST)

Comments regarding schedule

Length of Parkinson's (either as PWP or Carepartner)

New diagnosis (within a year)

1-5 years

More than 5 years

Personal goals for Support Groups