re+motivate program for people with  Parkinson's
Thanks for your interest in our program!    Complete our interest form and we will contact you after our workshop in December to get started.

Missed our workshop?  Sign up here and get the recording: https://forms.gle/3dV5B3hZtRbZ2i1D7

Our re+motivate program is an 8 week program of exercise, a motivation group and individual occupational therapy to set goals and set up a plan for long term healthy habits for PD.  We will have one cohort in January and another cohort in March.

The Parkinson's Foundation has provided grant funding for this program for people who are newly diagnosed with PD.

If you do not meet the criteria for our Parkinson's Foundation Program, we invite you to complete this form to participate in our other programs that meet your needs.
Email *
Name (first and last name) *
Pronouns
Gender identification
Email *
Have you participated in our programs before? *
Phone number *
Address *
What is the primary language spoken at home? *
What racial/ethnic group do you identify with? *
Are you newly diagnosed with Parkinsons?  (in the last 2 years) *
I am available to participate in weekly exercise, groups and individual sessions for 8 weeks in: *
Do you have online access if our program is online? *
Do you have any limitations in your ability to exercise at a high intensity (ie pain or joint problems, cardiac history, etc).  Please describe. *
Please check off the times of the day that you are available for our groups and sessions (you can choose more than one): *
Required
Please check off the days of the week that are best for you (you can choose more than one): *
Required
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of re+active physical therapy and wellness. Report Abuse
Google Forms