Request a peer mentor

Connect with someone who understands. Our peer mentors provide invaluable insights to help navigate life with paralysis. Enter your information and a program coordinator will respond as soon as possible.

Your information

* Which of the following best describes yourself?
If you are not the person with paralysis, which of the following best describes yourself?
Please indicate who is requesting a peer mentor. Check all that apply.
Has the person with paralysis ever served or are they currently serving in the Armed Forces (U.S. military)?
Which branch of the Armed Forces did the person with paralysis serve in?

The information below is optional. It will help the program coordinator refer you to the right peer mentor.

Paralysis information

When did the paralysis start?
What caused the paralysis?
Cause of spinal cord injury:
If you were Injured by Violence, please choose as many as apply:
If the Act of Violence Falls in One of these Categories, please choose as many as apply:
Position or level of spinal cord injury:
Type of paralysis:
Is a ventilator required?

Personal Information

Contact phone of person with paralysis:
How old is the person with paralysis?
What is the gender of the person with paralysis?
Marital status of the person with paralysis:
Is the person with paralysis of Hispanic, Latino, or Spanish origin?
What is the ethnicity of the person with paralysis?
Would the person with paralysis like info on how to enroll with the Veterans Administration?
What type of insurance does the person with paralysis have?
Would you like to receive our email newsletter and other Reeve updates?