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Person Needing Assistance Information
Prefix
Mr.
Mrs.
Ms.
Miss.
Other
Other Prefix
Person Needing Assistance's First Name
Person Needing Assistance's Middle Initial
Person Needing Assistance's Last Name
Suffix
Jr.
Sr.
Other
Other Suffix
Person Needing Assistance's Preferred Name
Does the Person Needing Assistance have a phone?
Does the Person Needing Assistance have a phone?
No
Does the Person Needing Assistance have a phone?
Yes
Person Needing Assistance's Phone Type
Seasonal
Mobile
Home
Business
Person Needing Assistance's Phone Number
OK to text?
OK to text?
No
OK to text?
Yes
Alt. Phone Number for Person Needing Assistance
OK to text alt phone?
OK to text alt phone?
No
OK to text alt phone?
Yes
Alt Phone Type for Person Needing Assistance
Seasonal
Mobile
Home
Business
Does the Person Needing Assistance have an email?
Does the Person Needing Assistance have an email?
No
Does the Person Needing Assistance have an email?
Yes
Person Needing Assistance's Email Address
Is the Person Needing Assistance a veteran?
Is the Person Needing Assistance a veteran?
No
Is the Person Needing Assistance a veteran?
Yes
Person Needing Assistance Preferred Contact Method
Email
Phone
Text
Date of Birth
Gender
Male
Female
Nonbinary
Other
Prefer not to answer
Other Gender
Race
Other Race
Pronouns
she/her/hers
he/him/his
they/them/theirs
Other
Other Pronoun
Is Person Needing Assistance diagnosed with ALS?
Is Person Needing Assistance diagnosed with ALS?
No
Is Person Needing Assistance diagnosed with ALS?
Yes
Other Diagnosis
Diagnosis Month
January
February
March
April
May
June
July
August
September
October
November
December
Diagnosis Year
Have you attended or are you attending an ALS clinic in your area?
Have you attended or are you attending an ALS clinic in your area?
No
Have you attended or are you attending an ALS clinic in your area?
Yes
ALS Clinic
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When searching for ALS Clinics, please start your search with an *
Caregiver & Clinician/Therapist Information
Caregiver Information
Does Person needing assistance have a caregiver?
Does Person needing assistance have a caregiver?
No
Does Person needing assistance have a caregiver?
Yes
Caregiver's Legal First Name
Caregiver's Legal Last Name
Caregiver's Relationship to Person Needing Assistance
Spouse/Partner
Parent
Child
Friend
Professional
Other
Other Relationship
Caregiver's Mobile Number
OK to Text Caregiver Phone?
OK to Text Caregiver Phone?
No
OK to Text Caregiver Phone?
Yes
Caregiver's Email Address
Does Caregiver Reside with Person Needing Assistance?
Does Caregiver Reside with Person Needing Assistance?
No
Does Caregiver Reside with Person Needing Assistance?
Yes
How did you hear about Team Gleason?
ALS Clinic
Therapist/Clinician
Social Media
Support Group
Other Individual Living with ALS
Online Web Search
Other Organization
In-Person Fundraiser/Event
Online Webinar/Event
Other
Other Source
Who is completing this form?
Person Needing Assistance
Caregiver
Clinician/Therapist
Other
Other Person's Relation to Person Needing Assistance
Other Person's First Name
Other Person's Last Name
Who would you like us to communicate with?
Person Needing Assistance
Caregiver
Both
Shipping Information
Please provide the address to which any equipment should be sent. No P.O. Boxes, please.
Search Address Here
Shipping Address Line 1
Shipping Address Line 2
Shipping Address City
Shipping Address State
Shipping Address Zip Code
Country
Please note that Team Gleason is only able to support persons needing assistance in the U.S. at this time. If you require assistance outside of the U.S., please use this
link
for potential resources.
Requested Services
Service(s)
Show Services
Show Services
No
Show Services
Yes
Service Type
Speech Language Pathologist Information
Are you working with a Speech Language Pathologist
Are you working with a Speech Language Pathologist
No
Are you working with a Speech Language Pathologist
Yes
Speech Language Pathologist's First Name
Speech Language Pathologist's Last Name
Speech Language Pathologist's Phone Number
Speech Language Pathologist's Email Address
Voice & Message Banking Information
Seeking Support or Funding
Seeking Support or Funding
Funding
Seeking Support or Funding
Funding & Support
Program to record voice/message
Acapela
ModelTalker
SpeakUnique
Voicekeeper
Other
Not Sure
Other Program to record voice/message
Wheelchair Seat Elevator Information
Are you working with a Durable Medical Equipment Company?
Are you working with a Durable Medical Equipment Company?
No
Are you working with a Durable Medical Equipment Company?
Yes
What Durable Medical Equipment Company are you working with?
Is a therapist/clinician helping with request
Is a therapist/clinician helping with request
No
Is a therapist/clinician helping with request
Yes
Specialty of the therapist or clinician
Occupational Therapist
Physical Therapist
Assistive Technology Professional
Specialist's First Name
Specialist's Last Name
Specialist's Phone Number
Specialist's Email Address
Equipment Information
What kind of equipment are you requesting?
Shower Chair
Portable Power Wheelchair
Ramps
Ability Drive
What type of request is this?
Co-Pay
Loaner
Insurance Denial
Adventure Information
Please describe the Adventure
Where would the adventure take place?
How many people would be going on the trip?
What is the approximate budget?
What are the potential Travel Dates
Does the applicant use the following
Is any other organization helping with trip?
Is this Adventure a Surprise?
Is this Adventure a Surprise?
No
Is this Adventure a Surprise?
Yes
Adventure Point of Contact First Name
Adventure Point of Contact Last Name
Adventure Point of Contact Phone Number
Point of Contact Email
Please describe what we may assist you with
Terms and Conditions
Media Terms & Conditions
Agree to Media Terms
Signature
Agree to Adventure Media Terms
Signature
Application Terms & Conditions
Agree to terms
Signature
Signature Date
