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Alzheimer's Association Cleveland Area Chapter

Mary Ertle

Address: 3 Summit Park, Suite 550 Independence, OH 44131

Phone: (216) 342.5583

Fax: (216) 373-0886

Email: cleveland-helpline@alz.org

Please provide as much information as possible, particularly highlighted fields

Provider:

Provider organization:

Provider phone:

Provider email:

Provider fax:

Name of person with memory loss:

Name of person being contacted:

How is the person being contacted related to the person with memory loss?

Self

Other

Phone:

Email:

Mailing address:

City:

State:

Zip code:

Preferred method of contact:

Phone

Mail

Preferred day/time of contact:

Monday - Friday between 8am - 4pm

The person being referred provided verbal consent instead of their signature

I accept the legal terms and conditions

24/7 Helpline 800-272-3900 / www.alz.org