NMT Foundation Application - NeuroMotion Telehealth

NMT Foundation Application

Our NMT Foundation is available to pay a scholarship of 80% of your monthly fee with NMT. The amount you would be responsible for monthly would be $30 and the NMT Foundation would pay the remaining $120. This would entitle you to 5 annual telehealth visits with one of our clinicians and access to Strive PD and Guardian (technology that would detect your Parkinson’s symptoms between visits with your NeuroMotion Telehealth clinicians).

If your application is accepted this would qualify you for one year of services and then be reevaluated annually for another scholarship.

Name of Applicant(Required)

First Last

Email(Required)

Phone(Required)

What is your relationship to the person with Parkinson's?(Required)

I am the one living with Parkinson's.

I am their care partner.

I am their son/daughter.

I am a family friend.

I am their service provider.

How did you hear about us?(Required)

Now let's get to know the person living with Parkinson's.

Name(Required)

First Last

Date of Birth(Required)

Date of Parkinson's Diagnosis(Required)

Status(Required)

First time applicant

Re-applying

Name of spouse or care partner(Required)

Address

Street Address Address Line 2 City State ZIP Code

Number in household(Required)

Please enter a number from 1 to 10.

Annual income(Required)

Any other notes or thoughts about your application?