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 (please specify)*

Marital Status

Primary language*

Other (please specify)*

Employment status

Other (please specify)*

Date Diagnosed (approximately)

How were you or the patient diagnosed?

Other (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 (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 (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 (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 (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