Request a peer mentor | Reeve Foundation

Your information

* Which of the following best describes yourself?

An individual living with paralysis

A caregiver family member or friend

Non-caregiver family member or friend

A healthcare professional

Other

Specify other

If you are not the person with paralysis, which of the following best describes yourself?

Parent

Spouse / Significant other

Sibling

Child

Extended family member

Friend

Healthcare worker

Please indicate who is requesting a peer mentor. Check all that apply.

Individual with paralysis

Family member and/or caregiver

* Your first name:

* Your last name:

* Your preferred language:

Language (if other):

Your preferred alternate language:

Language (if other):

* Your email:

* Retype your email:

* Your contact number:

Your preferred method of communication:

Your address:

City:

Country:

State

Zip / Postal Code:

Has the person with paralysis ever served or are they currently serving in the Armed Forces (U.S. military)?

Yes

Not sure

Which branch of the Armed Forces did the person with paralysis serve in?

Army

Navy

Marine

Air Force

Coast Guard

Merchant Marine

Not sure

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?

14 days or less

15 days to one year

Over one year

Not sure

What caused the paralysis?

Cerebral palsy

Disease

Guillain-Barre syndrome

Lou Gehrig's disease / ALS

Multiple sclerosis

Muscular dystrophy

Neurofibromatosis

Post-polio syndrome

Result of surgical or medical procedure

Spina bifida

Spinal cord injury

Stroke

Transverse myelitis

Traumatic brain injury

Not sure

Other

Specify other causes of paralysis

Cause of spinal cord injury:

Birth defect

Combat or service related (for military only)

Fall

From a surgery/ medical procedure

Motor vehicle accident

Sports/ recreation accident

Victim of violence

Workplace accident

Not sure

Other

Specify other causes of spinal cord injury

If you were Injured by Violence, please choose as many as apply:

Assault and/or Battery

Shooting

Stabbing

Intentionally Hit or Runover by Vehicle

Other

If the Act of Violence Falls in One of these Categories, please choose as many as apply:

Caregiver Violence

Domestic Violence

Gang Violence

Hate Crime

Military Service Related (Person with Paralysis is a military service member or veteran)

Warfare (Person with Paralysis was civilian)

Other

Position or level of spinal cord injury:

T10

T11

T12

Coccyx

Type of paralysis:

Paraplegia (T1 and below)

Quadriplegia (C8 and above)

Hemiplegia

Not sure

Other

Specify other types of paralysis

Is a ventilator required?

Yes

Not sure

Personal Information

First name of person with paralysis:

Last name of person with paralysis:

Country of person with paralysis:

State

Zip / Postal Code of person with paralysis:

Contact phone of person with paralysis:

Select where this phone is associated with

Language of person with paralysis:

Language (if other):

How old is the person with paralysis?

Unknown or unspecified

Birth to 9

10 to 19

20 to 29

30 to 39

40 to 49

50 to 59

60 to 69

70 or Older

What is the gender of the person with paralysis?

Man

Non-binary

Transgender

Woman

Prefer not to answer

Other

Unknown or unspecified

Marital status of the person with paralysis:

Married / Domestic Partner

Single

Divorced

Not sure

Is the person with paralysis of Hispanic, Latino, or Spanish origin?

Yes

Not sure

What is the ethnicity of the person with paralysis?

American Indian / Alaskan Native

Asian

Black / African American

Mixed Race

Native Hawaiian / Pacific Islander

White / Caucasian

Other

Specify other ethnicity of the person

Would the person with paralysis like info on how to enroll with the Veterans Administration?

Yes

Not sure

What type of insurance does the person with paralysis have?

COBRA

Medicaid

Medicare

Private Insurance

TriCare

Veterans Administration

Workers' Compensation

No Insurance

* Share with us why you want to connect with a peer mentor. This field is optional but your answer may help the matching process.

Would you like to receive our email newsletter and other Reeve updates?

Yes