Email *

I am a: * []

Type of caregiver: []

First Name *

Last Name *

Preferred name

Student #

Phone *

Address *

Country * []

State / Province * []

State - If Other * []

City * []

Zip * []

What is your age? * []

Gender * []

If Other:

Marital Status []

Preferred language * []

If Other:

Employment status []

If Other:

Please share why you want to connect with a peer mentor? * []

Year Diagnosed (approximately) [, Y: m: d:]

How were you or the patient diagnosed? []

If Other:

How long did it take to be diagnosed? (Experienced symptoms) []

Which tick-borne illnesses have you or the patient been diagnosed with having? (select all that apply) * []

If Other:

What stage of Lyme Disease are you or the patient in? * []

Primary symptoms (select all that apply) * []

Neurological (ex. headaches/migranes, fogginess, seizures, stroke, numbness...) Cognitive (i.e. forgetfulness/memory loss, confusion, difficulty concentrating...) Cardiac (i.e. lightheadedness, fainting, heart palpitations/chest pain...) Neuropsychiatric (ex. depression/anxiety, brain fog, mood swings, cognition, extreme fatigue, sleep disturbance, sensory sensitivity...) Joints/Arthritis (ex. Joint pain, swelling, Lyme arthritis POTS (Postural orthistatic tachycardia syndrome)

Treatment status []

How would you prefer to communicate with the person you are matched with? (select all that apply) []

Phone Email Text / SMS Video Chat

Which aspects of the Lyme journey would you like to receive support? (select all that apply) * []

Managing Lyme and employment Finding and evaluating Lyme physicians Making lifestyle adjustments (i.e. diet, fitness, daily routine) Addressing mental and emotional challenges Other

If Other:

Peer Code of Conduct

Peers will not practice, condone, facilitate or collaborate in any form of discrimination on the basis of ethnicity, race, sex, sexual orientation, age, religion, national origin, marital status, political belief, mental or physical disability, or any other preference or personal characteristic, condition or state.
Peers will respect the privacy and confidentiality of their Mentors and others utilizing peer support services and will only contact them during scheduled calls.
Peers will never engage in sexual/intimate activities with their Mentors and others utilizing peer support services.
Peers will avoid conflicts of interest that compromise the relationship between themselves and their Mentors.
Peers will never intimidate, threaten, harass, use undue influence, physical force or verbal abuse, or make unwarranted promises of benefits to their Mentors and others utilizing peer support services.
Peers will not accept gifts of significant value from their Mentors and others utilizing peer support services.
Peers will maintain high standards of personal conduct which includes keeping commitments to and giving dignity and respect to all people.

I agree to the Code of Conduct (see above) *

I agree to receive communications from GLA

Password * _{must be between
8 and 20 characters}

Password Confirm *

GLOBAL LYME ALLIANCE PEER TO PEER MENTOR PROGRAM

One on One Support Program

GET SUPPORT FROM A PEER MENTOR

My details

Demographic Information

Mentoring subjects

Mentoring preferences

More about you

Code of conduct

Peer Code of Conduct