Request a Mentor As a Peer who is participating in a Spinal Network Peer Mentoring Program, I understand that information obtained during Peer Mentoring sessions will be considered private and confidential. The information, however obtained, through direct interaction or digital transfer will remain with Spinal Network. The information may be shared within Spinal Network staff who are involved with the Peer or who have a need to know the information. At times, certain information may be used for purposes of performing program reviews or for developing program enhancements. At these times all identifying elements will be removed from the data prior to sharing. United Spinal will share data with legal authorities who duly request information in support of an investigation or legal action.Are you at least 18 years of age?* Yes No I have read and understood the above policies.* I have read and understood the above policies First Last PhoneEmail Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactName First Last Emergency PhonePersonal InformationGenderYour GenderMaleFemalePrefer Not to DiscloseBirthday MM slash DD slash YYYY RaceRace/EthnicityAfrican AmericanAsianCaucasianHispanicMixed RaceNative AmericanPacific IslanderPrefer Not to DiscloseMarital StatusMarital StatusDivorcedLiving TogetherMarriedSeparatedSingleWidowedPrefer Not to DiscloseEducation LevelEducationDoctorateMaster's DegreeBachelor's Degree (4 year degree)Associate's Degree (2 year degree)Presently Attending CollegeMilitary Special TrainingProfessional DegreeVocational DegreeHigh School Diploma/GEDPresently Acquiring High School DegreeDid not complete high schoolInsuranceInsuranceMedi-gapMedicaidMedicareVeterans AdministrationVAPrivate InsurancePrivateOut of PocketNoneWere you referred by someone Are you a US Veteran? Yes No Primary Disability*Primary DisabilityAmputeeAmyotrophic Lateral SclerosisCerebral PalsyMultiple SclerosisMuscular DystrophyPolioSeizure DisorderSpina BifidaSpinal Cord Injury - ParaplegicSpinal Cord Injury - QuadriplegicStrokeTransverse MyelitisTraumatic Brain InjuryNoneYear of Injury/Onset MM slash DD slash YYYY Rehab Facility Hobbies and InterestsPrevious MentoringPriorities (select as many as apply) Understanding my disability Coping with disability Coping with sadness & depression Coping with anger & frustration Outlook on life Communicating with family & friends Self advocacy Settings goals Achieving goals Identifying community resources Community involvement Other Assign Mentor Based On (select as many as apply) Similar Age Similar Education Similar Gender Similar Marital Status Similar Race/Ethnicity Similar Interests Similar Disability No Preference CAPTCHA Δ
