Apply to become a mentor

I am a*

I am a caregiver to*

First name*

Last name*

Address*

Address 2

Country*

City*

State*

City/State/Province*

Zip Code*

Email*

Phone*

Demographic Information

What is your age?*

Gender*

Other Gender (please specify)*

Marital Status

Primary language*

Other Language (please specify)*

Employment status

Other Employment Status (please specify)*

Date Diagnosed (approximately)

How were you or the patient diagnosed?

Other Method of Diagnosis (please specify)

How long did it take to be diagnosed? (Years)

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

Other tick-borne illness (please specify)*

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

Primary symptoms - Select all that apply*

Neurological LD (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
Wish I had help from someone who understood what I was going through during my diagnosis experience
In honor or in memory of someone
For religious or spiritual reasons
Help me through my own healing process
Other

Other reason you're interested (please specify)*

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

Other level of support (please specify)*

How often would you like to communicate with your (personalized) peer match

How would you prefer to communicate with the person you are matched with?*

Phone
Email
Text
Video chat

Which aspects of the Lyme journey do you feel particularly suited to speak to?*

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

Other Aspects of the Lyme Journey (please describe)*

*

I agree to the Code of Conduct

Demographic Information

My Interest in becoming a Peer Mentor

Peer to Peer Mentor ProgramCode of Conduct

Peer to Peer Mentor Program
Code of Conduct