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
Are you under the age of 18?
Please select...
Yes
No
Parent / Legal Guardian
If you are under the age of 18 please fill out the information below:
Parent/Legal Guardian Phone Number:
Parent/Legal Guardian Email:
Parent/Legal Guardian Name:
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.
Did you or your loved one do inpatient rehabilitation at Shepherd Center?
Please select...
Yes
No
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
Date of onset of complex neurological condition?
If other, please explain:
Are you interested in volunteering to be a Peer Mentor?
Please select...
Yes
No
Contact Information