Peer Connect Request

Enter your information below to be matched with a Peer Connect Leader. You will be contacted by the SRNA team within one week of receiving your submission. If you would like help completing the form, contact us.

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Contact Information

First Name Last Name

Preferred Language (Optional)

Email

Yes, sign me up for email updates.

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(Optional)

About You

What is your gender?

Female Male Other Transgender

The Peer Connect Program is available to SRNA members. If you are not already a member, you can sign up for free here.

Are you a member of SRNA?
Are you a member of SRNA? is required.

Yes

No

Why do you want to connect to a peer? What do you hope a peer can help you with?

What questions, concerns, or topics would you like to discuss with a peer related to rare neuroimmune conditions?

Please describe your experience with the disorder and how it has impacted your life. (For example - what symptoms you have, what parts of your body are affected, what adaptations do you use?)

How would you prefer to connect?
How would you prefer to connect? is required.

Phone call

Email

Text Message

Video Call

Other Other

What contact information can we share with your peer? (Initially, you will be introduced to your peer via email.)
What contact information can we share with your peer? (Initially, you will be introduced to your peer via email.) is required.

Email Address

Phone Number

Mailing Address/Location

Please provide the name of an emergency contact below.

We ask for this information in the rare case of a healthcare or safety emergency arising while speaking with your peer. This information is only available to SRNA staff in the event of an emergency.

Emergency Contact Name

Emergency Contact Phone Number (Optional)

Emergency Contact Email Address

Upon submitting this form, I acknowledge I will be matched with a Peer Connect Leader. I give permission for the peer to receive my contact information.

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