Virtual Support Group Registration
After registration completion you will receive an instructional email and a web link to join the video conference at the corresponding date and time.
TUESDAY May 11th, 6:30 pm - 7:30 pm
Persons living with ALS, their family members, friends and caregivers are welcome to attend our chapter support groups. These groups are an opportunity to meet others, learn about new information and resources, and provide or receive support and encouragement.
First and Last Name
I am a ... (please check all that apply)
person diagnosed with ALS
spouse to someone diagnosed with ALS
child of someone diagnosed with ALS
family member, not spouse or child, of someone diagnosed with ALS
friend of someone who is diagnosed with ALS
caregiver for someone diagnosed with ALS
Who is your Care Service Coordinator?
Unknown / Not Applicable
We will be meeting virtually and long distance using a web video conferencing platform, Ring Central. Telephone call in is available as well. For video, a built in or plug in accessory web camera with microphone is required. Do you need assistance familiarizing yourself with set up?
In your opinion how often do you suggest this group meets?
Every Other Week
Regarding Confidentiality: Anything said between any two or more group members at any time is part of the group and is confidential. I understand that everything said in this group is confidential and not to be shared with anyone outside of the group, except as may be otherwise required by law. I agree to keep confidential the names of other members of the group and what is said in the group. As a member of this group, I agree to not disclose to anyone outside the group any information that may identify another group member. This includes, but is not limited to, names, physical descriptions, biological information, and specifics to the content of interactions with other group members. I agree to indemnify and hold ALS Association St.Louis Regional Chapter harmless for any loss or damages, including costs and attorney’s fees, incurred by ALS Association St.Louis Regional Chapter as a result of my breach of another’s confidentiality. Further information regarding these situations and my privacy rights will be provided in the Notice of Privacy Practices for Protected Health Information I also understand that anything said in group is confidential, except for the following limitations: ●Child abuse or neglect ● Vulnerable adult abuse or neglect ●Threats to harm oneself ● Threats regarding harm to another person ● A court subpoena
I DO NOT consent at this time and would like to discuss further.
I indicate that I have read carefully and understand and agree to the above statements.
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