Ice Bucket Challenge Progress

 

2018 Patient and Caregiver Survey

 

The ALS Association Indiana Chapter is commited to adressing the most pressing needs of individuals living with ALS, their caregivers, family, and friends.  The Care Services goal is to build an informed, empowered and well-cared for ALS community. Your responses to the following survey will guide the Chapter's Strategic Plan to support your needs.  We look forward to serving you and your family members. 

 

General Information

1.


2. What County do you live in?
(Select one of the available choices or enter a different value.)



3.  


4. How did you hear about the ALS Association?
(Select one of the available choices or enter a different value.)



 

Programs and Services

*5. Which Multidisciplinary Clinic do you or a loved one attend?
(Select one of the available choices or enter a different value.)



6.

(Maximum response 255 chars, approx. 5 rows of text)

7.
Question - Not Required - What Programs do you/your family access through The Chapter?

8.


9.

(Maximum response 255 chars, approx. 5 rows of text)

10.
Question - Not Required - What three areas do you believe The Chapter should be devoting more Care Services resources to?
Please make up to 3 selections from the choices below.

11.

(Maximum response 255 chars, approx. 5 rows of text)

 

Additional Comments for ALS Staff

 

For additional information on Chapter Programs/Services/Events please provide the following information. 

12.  


13.  


14.  


15.

(Maximum response 255 chars, approx. 5 rows of text)

   Please leave this field empty