ALS Canada Caregiver Mental Health Program – Caregiver Intake Form

For caregivers of people living with ALS across Canada

Thank you for your interest in ALS Canada’s Mental Health Program. This program is designed to offer emotional and mental health support to caregivers currently supporting people living with ALS. This program enables eligible caregivers to access up to four 50-minute virtual therapy sessions with a registered therapist – at no cost, provided the sessions are used within six months of referral. Program participants have the option to continue therapy sessions at their own cost after the four ALS Canada funded sessions have been completed.

The program uses a goal-based therapy approach, where caregivers and therapists work together to identify meaningful goals, track progress, and foster coping skills that support caregivers' wellbeing throughout.

By completing the following form, you are providing consent for ALS Canada to share the below information with AWC Grief Support. If there are any questions about ALS Canada’s Caregiver Mental Health Program, please contact [email protected].

First name

Last name

Email address

Street

City

Province / State

Postal code

Country

Phone number

Name of the person living with ALS:

What is the relationship to you?:

Are you currently receiving any counselling or mental health services?

Yes

No

If yes, please describe:

Have you previously accessed counselling, therapy, or support groups (ALS or non-ALS)?

Yes

No

If yes, please describe:

Is there anything that might impact your participation in virtual therapy sessions (technology, scheduling, accessibility)?

Yes

No

If yes, please describe:

How did you hear about the program?

For ALS Canada to provide the most accurate information for referral and to match you with the appropriate therapist, please complete the following questions:

Reason for accessing therapy

Please briefly describe why you are seeking therapy at this time. (Examples: coping with stress, grief, emotional strain, caregiving challenges, burnout, specific concerns)

Goals for therapy

What would you like to gain from participating in this therapy program? (Goal-based therapy is a core element of the program.)

The ALS Society of Canada (ALS Canada) respects your privacy. We protect your personal information and adhere to all legislative requirements in the protection of your privacy. The information you provide will be used to deliver services through AWC Grief Support and to keep you informed and up-to-date on the activities of ALS Canada, including newsletters, programs, services, advocacy, awareness, and fundraising initiatives. Please see our privacy policy at www.als.ca/privacy-policy for further information. We do not rent or sell our mailing lists.

Through the Caregiver Mental Health Program, virtual visits are part of the services you receive from ALS Canada and AWC Grief Support. While beneficial, it is important to acknowledge the limitations and risks of virtual visits, which include the potential for eavesdropping, hacking, and software failures.

You may withdraw your consent at any time. However, ALS Canada may be limited in the services it may be able to provide without consent for the collection, disclosure, and use of personal information. Please notify us of any changes by phone at 1-800-267-4257 or via email at [email protected].