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Peer to Peer Mentor Program
ABOUT
THE PROGRAM
TESTIMONIALS
REGISTRATION
CONTACT
Please fill out all required fields.
BECOME A PEER MENTOR AND SUPPORT OTHERS WHO ARE LIVING WITH LYME DISEASE AND OTHER TICK-BORNE ILLNESSES
Support others who are living with Lyme disease and other tick-borne illnesses
What is a GLA Peer Mentor?
Someone who has been affected by Lyme disease and/or other tick-borne illness and wants to “get involved and do more” to support others who are currently trying to navigate their way through the journey. GLA peer mentors are:
- Empathetic and want to support others who are seeking support and guidance
- Understand how overwhelming it is living with Lyme disease and/or other tick-borne illness
- Have a positive outlook on their own journey with Lyme disease
- Knowledgeable and willing to share what they have learned
Who are GLA Mentors?
If you have been affected by Lyme disease or other tick-borne illness and are passionate about supporting others in the Lyme community that include patients, caregivers, and family members. Peer mentors are empathetic and can provide emotional support and understanding to someone who is living with Lyme disease and/or other tick-borne illness.
- You’ve been diagnosed with Lyme disease and/or other tick-borne illnesses and are willing to share what you have learned and your experiences to help someone overcome their challenges You are a caregiver, family member, or spouse who has been actively involved in supporting someone with Lyme and/or other tick-borne illness
- You are a parent who has or is still managing a child who was diagnosed with Lyme and/or other tick-borne illness A spouse who has supported their partner through their illness and can provide guidance and insight into maintaining a healthy family dynamic
To apply, you should:
- Have at least 1 years’ experience living with Lyme disease and/or other tick-borne illness – patient, caregiver, parent, spouse, or other family members
- Have a positive outlook on your own journey with Lyme
- Have time to volunteer to support others
- Have good interpersonal skills
- Willing to listen and continue to learn about Lyme and how it has affected others
- Willing to share your experiences
- Willing to follow GLA established guidelines
- Willing to have a background check
Please fill the form below to register as a mentor:
My details
Email
*
I am a:
*
Select
Patient - Living with Lyme disease
Caregiver
Patient and Caregiver
Type of caregiver:
[]
Select
Son/daughter
Spouse/partner
Sibling
Parent
Friend
First Name
*
Last Name
*
Preferred name
Student #:
[]
Phone
*
[]
Address
*
[]
[]
Country
*
[]
Select
US
Canada
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of The
Cook Islands
Costa Rica
Cote D'ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and The Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
State / Province
*
[]
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon
State - If Other
*
[]
City
*
[]
Zip
*
[]
Demographic Information
What is your age?
*
[]
Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or Above
Prefer not to answer
Gender
*
[]
Select
Female
Male
Transgender
Other
Decline to answer
If Other:
Marital Status
[]
Select
Single
Married
Partner
Divorced
Widowed
Preferred language
*
[]
Select
English
Spanish
French
Other
Afrikaans
Albanian - shqip
Amharic - አማርኛ
Arabic - العربية
Aragonese - aragonés
Armenian - հայերեն
Asturian - asturianu
Azerbaijani - azərbaycan dili
Basque - euskara
Belarusian - беларуская
Bengali - বাংলা
Bosnian - bosanski
Breton - brezhoneg
Bulgarian - български
Catalan - català
Central Kurdish - کوردی (دەستنوسی عەرەبی)
Chinese - 中文
Chinese (Hong Kong) - 中文(香港)
Chinese (Simplified) - 中文(简体)
Chinese (Traditional) - 中文(繁體)
Corsican
Croatian - hrvatski
Czech - čeština
Danish - dansk
Dutch - Nederlands
Esperanto - esperanto
Estonian - eesti
Faroese - føroyskt
Filipino
Finnish - suomi
Galician - galego
Georgian - ქართული
German - Deutsch
German (Austria) - Deutsch (Österreich)
German (Germany) - Deutsch (Deutschland)
German (Liechtenstein) - Deutsch (Liechtenstein)
German (Switzerland) - Deutsch (Schweiz)
Greek - Ελληνικά
Guarani
Gujarati - ગુજરાતી
Hausa
Hawaiian - ʻŌlelo Hawaiʻi
Hebrew - עברית
Hindi - हिन्दी
Hungarian - magyar
Icelandic - íslenska
Indonesian - Indonesia
Interlingua
Irish - Gaeilge
Italian - italiano
Italian (Italy) - italiano (Italia)
Italian (Switzerland) - italiano (Svizzera)
Japanese - 日本語
Kannada - ಕನ್ನಡ
Kazakh - қазақ тілі
Khmer - ខ្មែរ
Korean - 한국어
Kurdish - Kurdî
Kyrgyz - кыргызча
Lao - ລາວ
Latin
Latvian - latviešu
Lingala - lingála
Lithuanian - lietuvių
Macedonian - македонски
Malay - Bahasa Melayu
Malayalam - മലയാളം
Maltese - Malti
Marathi - मराठी
Mongolian - монгол
Nepali - नेपाली
Norwegian - norsk
Norwegian Bokmål - norsk bokmål
Norwegian Nynorsk - nynorsk
Occitan
Oriya - ଓଡ଼ିଆ
Oromo - Oromoo
Pashto - پښتو
Persian - فارسی
Polish - polski
Portuguese - português
Portuguese (Brazil) - português (Brasil)
Portuguese (Portugal) - português (Portugal)
Punjabi - ਪੰਜਾਬੀ
Quechua
Romanian - română
Romanian (Moldova) - română (Moldova)
Romansh - rumantsch
Russian - русский
Scottish Gaelic
Serbian - српски
Serbo-Croatian - Srpskohrvatski
Shona - chiShona
Sindhi
Sinhala - සිංහල
Slovak - slovenčina
Slovenian - slovenščina
Somali - Soomaali
Southern Sotho
Spanish (Argentina) - español (Argentina)
Spanish (Latin America) - español (Latinoamérica)
Spanish (Mexico) - español (México)
Spanish (Spain) - español (España)
Spanish (United States) - español (Estados Unidos)
Sundanese
Swahili - Kiswahili
Swedish - svenska
Tajik - тоҷикӣ
Tamil - தமிழ்
Tatar
Telugu - తెలుగు
Thai - ไทย
Tigrinya - ትግርኛ
Tongan - lea fakatonga
Turkish - Türkçe
Turkmen
Twi
Ukrainian - українська
Urdu - اردو
Uyghur
Uzbek - o‘zbek
Vietnamese - Tiếng Việt
Walloon - wa
Welsh - Cymraeg
Western Frisian
Xhosa
Yiddish
Yoruba - Èdè Yorùbá
Zulu - isiZulu
If Other:
Employment status
[]
Select
Student
Full Time
Part Time
Student
Homemaker
Retired
Disability
Other
If Other:
Mentoring subjects
Year Diagnosed (approximately)
[, Y: m: d:]
-
January
February
March
April
May
June
July
August
September
October
November
December
-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
How were you or the patient diagnosed?
[]
Select
Western blot/ELISA
Clinical
I don't know
Other
If Other:
How long did it take to be diagnosed? (Experienced symptoms)
[]
Select
Less than 3 months
Less than a year
1-2 years
2-4 years
More than 4 years
I don't know
Which tick-borne illnesses have you or the patient been diagnosed with having? (select all that apply)
*
[]
Lyme disease
Bartonella
Babesia
Ehrlichia/Anaplasma
Spotted fever
Powassan
STARI
Alpha-Gal syndrome
Other
If Other:
What stage of Lyme Disease are you or the patient in?
*
[]
Select
Early Lyme
Late - stage / Chronic
Post-treatment Lyme Disease
I don't know
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
*
[]
My Interest In Becoming A Peer Mentor
Why are you interested in becoming a Peer mentor
*
[]
Want to help and give back to others
In honor or in memory of someone
Help me through my own healing process
Wish I had help from someone who understood what I was going through during my diagnosis experience
For religious or spiritual reasons
Other
If Other:
Why do you believe you are qualified to serve as a Peer Mentor? Up to 100 words
*
[]
Please share the level(s) of support you want to provide. (select all that apply)
[]
I am willing to listen to someone's concerns relating to their diagnosis
I want to give emotional support to someone diagnosed/living with (chronic) Lyme disease
I have the desire to support and inspire others living with Lyme disease
I believe that my personal experience living with LD has given me a greater sense of meaning and purpose
I would like to share my experiences being a caregiver
I have experience finding resources and can help guide someone through their journey
Other
If Other:
Which aspects of the Lyme journey do you feel particularly suited to speak to? (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:
Code of conduct
Peer to Peer Mentor Program
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.
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 theirMentors.
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 that includes keeping commitments to and giving of dignity and respect to all people.
I agree to the Code of Conduct (see above)
*
I agree to receive communications from GLA
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