Support Group Survey
This fall, The Brain Tumor Foundation will be announcing a new series of support groups for brain tumor patients, their caregivers and loved ones. Participants will be enabled to discuss common issues, share personal stories and helpful information, and overall, feel less isolated, because no one should battle a brain tumor alone.
In order to establish the days, times, locations and frequency of our new series of support groups, The Brain Tumor Foundation has prepared the following survey and is interested in your feedback.
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| Fields marked * are required |
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| First Name* |
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| Middle Initial |
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| Last Name* |
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| Company/Organization |
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| Address* |
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| City* |
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| State* |
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| Zip* |
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| Tel. Home* |
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| Tel. Alt. |
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| Fax |
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| E-mail |
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*I. I am a: (select one)
Patient diagnosed with a benign brain tumor
Patient diagnosed with a malignant brain tumor
Caregiver of a family member/friend with a brain tumor
Medical professional/clinician
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| 2. I would be interested in attending a support group for* (check all that apply):
Patients with a benign brain tumor
Patients with a malignant brain tumor
Caregivers
Patients and caregivers
Those seeking bereavement services
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| 3. I know someone else who would be interested in attending a support group for, their contact information is: |
| First Name |
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| Middle Initial |
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| Last Name |
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| Company/Organization |
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| Address |
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| City |
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| State |
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| Zip |
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| Tel. Home |
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| Tel. Alt. |
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| Tel. Cell |
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| Fax |
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The above person would be in a group for:
Patients with a benign brain tumor
Patients with a malignant brain tumor
Caregivers
All patients and caregivers
Patients seeking bereavement services
I cannot recommend another person at this time
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| 4. I would be able to participate in a support group in midtown Manhattan on the following days/times this fall (choose all that apply)*:
Tuesday evenings on a weekly basis from 4:00 PM - 5:30 PM
Tuesday evenings on a weekly basis from 5:00 PM - 6:30 PM
Tuesday evenings once a month from 4:00 PM - 5:30 PM
Tuesday evenings once a month from 5:00 PM - 6:30 PM
None of the above
Other (please suggest other days and times that would be preferable)
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| 5. I would prefer weekly basis support group meetings to be
On a six week schedule
Open-ended
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| 6. I would be interested in a support group in another part of New York City and/or the country (please explain):
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7. I would be interested in a phone support group that would meet on a designated day and time. Registration would be required and a call in number would be provided to participants in advance.
Yes No
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8. The Brain Tumor Foundation's “Phone a Friend” Program matches brain tumor patients, their family members or loved ones around the country with a facilitator by phone for a one-on-one session.
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a) I am interested in “Phone a Friend” for (choose all that apply):
Myself
Someone else (please explain) |
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b) I would be available to speak to a “Phone a Friend” on the following days/times (choose all that apply):
Weekdays in the morning hours
Weekdays in the evening hours
Weekends in the morning hours
Weekends in the evening hours
Other (please explain) |
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