Alzheimer's Association

National Site  |   About Us  |  Donate  |  Advocate  |  Media  |  Contact Us  |  Español

Site Map

Greater Illinois Chapter Change Location

 Early Stage/Early Onset Focus Groups and
 Interviews Participation Form




We will be conducting focus groups so that we can develop programs and services that meet your needs. If you are unable to participate in a focus group, there will be limited opportunities for individual interviews.

If you are willing and able to participate in a focus group, please fill out the form below and click "submit". Once we receive your application, you will be contacted with further information. We appreciate your time and consideration. Please feel free to contact Nicole Batsch, Early Stage Director at (847) 933-2413 with any questions.

Privacy Statement
The personal information you are providing will be kept strictly confidential. In submitting this information you agree that you are doing so voluntarily and only for the purposes of this study. Results will be reported from this study, but only in aggregate form and not in any way that identifies you.

Participation
No, I do not wish to participate, but would like to receive information on the results and have provided my contact information below.
Yes, I would like to participate in, and have provided my contact information below:
My family member(s) would also like to participate and his/her information is included below:

Diagnosed Individual
Name
Address
City
State
Zip
Phone
Email
What is your diagnosis?
Age of Onset
Current Age
Name of diagnosing neurologist
Name of Diagnostic Center (if applicable)

Primary Family Member(s)
Name
Relationship
Address
City
State
Zip
Phone
Email
If a child or children would like to participate, please include names ages and relationship. Must be over 10 years old.

Security & Privacy Policy Disclaimer Copyrights & Reprints About this Site Contact Us

Chapter Headquarters
Greater Illinois - 8430 W. Bryn Mawr, Suite 800,
Chicago, IL 60631 Phone 847.933.2413

Alzheimer's Association National Office 225 N. Michigan Ave., Fl. 17, Chicago, IL 60601
© 2007 Alzheimer's Association. All rights reserved.

24/7 Helpline: 1.800.272.3900