Request a Peer Mentor

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.

  • Emergency Contact

  • Personal Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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