Join Our Peer Support Community
Submit this form to be added to our invitation for the Peer Support Community.
First Name
Last Name
Street
City
State
Zip/Postal Code
Email
Phone Number
Date of Birth
Date you experience the onset of your condition?
Type of Condition
Please select...
Spinal Cord Injury
Brain Injury
Stroke
Concussion
Guillain-Barré
MS
Other Neurological Condition
Autoimmune Disorder
Please specify injury location. You can select more than one.
C1-C3
C4-C5
C6-C8
T1-T6
T7-T11
T12-L2
L3-S5
If other, please explain:
Did you or your loved one do inpatient rehabilitation at Shepherd Center?
Please select...
Yes
No
Do you personally have a complex neurological condition, or are you a family member or a caregiver of someone with a neurological condition?
Please select...
I am living with a neurological condition.
My family member/someone I care for is living with a neurological condition.
Are you interested in volunteering to be a Peer Mentor?
Please select...
Yes
No
Contact Information