I AM ALS Peer Support Initiative: Mentee Application

All information shared through this application will be kept confidential, and will not be shared without your explicit consent.

Date of birth

Date

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

I have been diagnosed with ALS

I am the primary caregiver for a loved one with ALS

I am a loved one of someone diagnosed with ALS

I lost someone diagnosed with ALS

Other (please specify)

Self

I am their spouse

I am their domestic partner

I am their parent

I am their adult child

I am their friend

I am their paid caregiver

Other (please specify)