New Support Group Application
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1. Request to Start an HDSA Support Group
Below is the application to start an HDSA Support Group. If you have any questions, please feel free to contact Seth J. Meyer at SMeyer@HDSA.org. Thank you for your interest.
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1
. Please enter your contact information below.
Please enter your contact information below.
Name:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Email Address:
Phone Number:
2
. Do you have a location planned for the group?
Do you have a location planned for the group?
Yes
No
3
. If yes, please list the location that you plan to use.
If yes, please list the location that you plan to use.
Company:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
4
. Is there a cost to use the location?
Is there a cost to use the location?
Yes
No
*
5
. Are you planning on having a volunteer facilitator or a paid facilitator?
Are you planning on having a volunteer facilitator or a paid facilitator?
Volunteer
Paid
*
6
. Is this a peer led group or a professionally led group? A peer led group would be run by any interested party. A professionally led group is generally run by a Social Worker, Family Therapist, Genetic Counselor, or Nurse.
Is this a peer led group or a professionally led group? A peer led group would be run by any interested party. A professionally led group is generally run by a Social Worker, Family Therapist, Genetic Counselor, or Nurse.
Peer Led
Professionally Led
*
7
. Who will be the target group members? (Please check all that apply)
Who will be the target group members? (Please check all that apply)
People with HD
People at-risk
Family Members/Caregivers
Teens
All-Inclusive Group
Other (please specify)
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