Provider Company *

Doctor/Physician *

Title

First Name *

Last Name *

Credentials *

Email *

Website *

Phone * []

Other Phone

Practice Type - 1: *

General Practitioner / Internist Functional / Alternative / Integrative

Practice Type - 2:

If Other:

Category 2: []

Student #: []

Do you provide remote telemedicine - in your state? []

Do you provide remote telemedicine - in the whole country? []

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:

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) []

Relevant categories []

If Other:

Are you an ILADS member or have you attended any ILADS events * []

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 * []

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:

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.

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Listing Admin Contact

Directory Listing Details

Special Info

Peer to Peer Mentor Program
Code of Conduct

Listing Admin Contact

Directory Listing Details

Special Info

Peer to Peer Mentor ProgramCode of Conduct

Peer to Peer Mentor Program
Code of Conduct