Care Services Intake Form

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The ALS Association provides a wide range of information, education, care, and support services to those living with ALS and their families.

Please provide the following information related to the person with ALS, their environment, and their current ALS symptoms. This will allow us to assist with the most appropriate and timely services.

You may submit a partially or fully completed form. A chapter care service staff member will contact you directly with additional information and resources. 


Person diagnosed with ALS














Please specify


Please specify


















Diagnosis Information

Diagnosis















FTD is also known as frontotemporal dementia, frontotemporal lobar degeneration (FTLD), or Pick’s disease.



Genetic counselors are trained to help individuals and families understand their family history, the genetics of ALS and how genetic testing may impact their lives.




Medications, Environment and Assistive Devices

Medications


Your Environment


Contact Information for Support Person











Assistive Devices





Participation and Submit

Participation

The Centers for Disease Control and Prevention established the National ALS Registry to collect and analyze data about people living with ALS.

Clinical trial: In a clinical trial, participants receive an intervention, such as drugs or devices; procedures; diet changes. Observational Study: An observational study is sometimes called an observational clinical trial. The participants health data is collected and analyzed over time. An observation study does not intervene or change a participant's medical care. Survey Research: In survey research, the participant answers survey questions on paper, online, in person, or over the phone.







Thank you for sharing information that will allow us to provide you with the most timely and appropriate information, care, and support. 

You may submit your information now; a chapter care service staff member will follow-up with you via your preferred communication mode
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Contact Information