I Am ALS

Request Support

  Please complete and submit this form to request support from I AM ALS Navigation. Fields with an * are required. I AM ALS currently supports adults (18 years of age or older) who are affected by ALS and who live in the United States only.  
  * - required  
I am filling out this form for * Myself On behalf of someone else
What is your connection to ALS? *
Your Name * First Middle Last Suffix
Your Gender
What ethnicity do you identify with?
Your Birth Date * MM/DD/YYYY
Diagnosis date MM/DD/YYYY
Your Address Street
City
State Zip *
Zip code of person who needs support (if different from yours):
Are you a Veteran? *
How would you like us to contact you? *
Email address:
Phone number:
Are there any accommodations we should make to communicate with you effectively?
What are you looking for help with? Select all that apply. * Understanding ALS and care options
Financial assistance
Insurance Eligibility, Enrollment, or Appeal Assistance
Clinical trials and other research opportunities
Emotional Support
Employment and legal assistance
Support with day-to-day activities
End of life care needs
I’m not sure
Other - please explain
How did you hear about us?
  * I certify that all of the information I provided is accurate.
By submitting this form, I agree to have I AM ALS, an I AM ALS partner or any community resource identified to contact me to provide requested services, follow up and request feedback for quality assurance. I agree that I am submitting this form for the purpose of receiving information and resources about the needs checked above and understand that the contact and background information provided on this form will be used for this service only.
I acknowledge that I AM ALS does not provide medical advice or guidance. I will consult my health care provider for medical advice or guidance on decisions that may impact my health. I acknowledge that I AM ALS does not provide direct financial assistance.

* I accept the terms of service.