Newly Diagnosed Support Groups

Hospital or healthcare/medical institution you're affiliated with(Required)

Participant Information

Mobile Phone(Required)

Who lives in the home with the patient and you?(Required)

Patient/Survivor Information

Patient/Survivor's Date of Birth(Required)

Patient/Survivor's Date of Brain Tumor Diagnosis(Required)

Hospital(s) where patient is or was treated(Required)

Please describe current treatment(Required)

What ongoing complications and/or late-term effects, if any, has the patient experienced?(Required)

Additional Information

Note: Please provide a little more detail about yourself and your child to help us better understand your current situation. Each question in this section requires an answer. Your answers will be reviewed by PBTF team members to ensure that this program is a good fit for you and will meet your needs. You may receive a follow-up call from a PBTF team member for further clarification of your responses.

What challenges or stressors do you currently face as a result of the patient’s brain tumor diagnosis and treatment?(Required)

Who is currently in your support system? Include friends, family members, church or other groups providing support.(Required)

Have you attended a support group previously? If so, please tell us a little bit about your experience.(Required)

Are there any specific topics you would like to see discussed in an online support group?(Required)

What do you hope to gain from participating in an online support group?(Required)

Virtual Support Group Commitment

The Pediatric Brain Tumor Foundation’s Virtual Support Groups are held every other week through Zoom for 8 to 10 sessions. This program offers an online support group experience for parents and caregivers of pediatric brain tumor patients to meet others like them, share their stories, and empower each other to manage the challenges presented by treatment and all that follows. As a valued member of the group, we ask you commit to the entire program by attending every group session. We understand from time to time circumstances will arise that may prevent you from attending. Please contact the facilitator and/or PBTF family support staff if you are unable to attend one of the scheduled sessions.

Name

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Email Address(Required)

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Support for Families

Participant Information

Patient/Survivor Information

Additional Information

Virtual Support Group Commitment

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