Healthcare Provider Program - Global Lyme Alliance

The information below would help narrow your search to the providers that are best for you.

My details

Your login profile info

Email *

I am a: * []

Type of caregiver: []

First Name *

Last Name *

Preferred name

Student #

Phone

Search Location

This helps us find the providers that you can access

Would you use telemedicine? []

Location #1:

Country * []

Zip

State / Province

If Other []

City

Location #2:

Country * []

Zip

State / Province

If Other []

City

Preferred language[]

If Other:

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

Search Info

This helps us find the relevant provider for you

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) []

If Other:

Type of providers that I am looking for:

General Practitioner / Internist Functional / Alternative / Integrative

If Other:

Were you diagnosed?[]

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)

Notes []

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:

Terms & Conditions

Participants 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.
Participants will respect the privacy and confidentiality of their Mentors and others utilizing peer support services.
Participants will never engage in sexual/intimate activities with their Mentors and others utilizing peer support services.
Participants will avoid conflicts of interest that compromise the relationship between themselves and theirMentors.
Participants 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.
Participants will not accept gifts of significant value from their Mentors and others utilizing peer support services.
Participants 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 Terms & Conditions (see above) *

I agree to receive communications from GLA

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

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Global Lyme Alliance - Healthcare Provider Directory

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Terms & Conditions

Terms & Conditions