Please complete and submit this form to request support from the ALS Support Team. Fields with an * are required. I AM ALS currently supports adults (18 years of age or older) who are impacted 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 *

Are you transgender?

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 type of health insurance do you have? (Select all that apply) * Medicare
Medicaid
Private Insurance (please specify)
VA
Tricare
I am in the process of applying for Medicare/Medicaid
I do not have health insurance
My insurance is not listed (please specify)
I prefer not to respond

Which ALS Clinic do you go to for care?

How did you hear about us? *

This next question asks how you feel about different aspects of your life. For each one, indicate how often you feel that way. *

How often do you feel that you lack companionship? Hardly Ever Some of the time Often

How often do you feel left out? Hardly Ever Some of the time Often

How often do you feel isolated from others? Hardly Ever Some of the time Often

I would like to receive email updates from I AM ALS.

* 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.

Request Support