Lupus Buddy Program Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Female
Male
Other
Age
*
Date diagnosed with lupus ((please enter '1' for day if you do not remember the exact date - month and year are sufficient)
*
Type of Lupus You Have (such as SLE, nephritis, etc.)
*
Do you consider yourself (please choose one)
*
A patient with a great deal of experience and knowledge about lupus
A patient who is beginning to learn about lupus
Other
Are you Interested in being paired with a buddy at this time?
*
Yes
No
I'm not sure- I'd like more information
I am interested in becoming a Buddy
What is the one thing you would most want out of the Buddy Program?
How much time per month (in hours) would you be willing to invest in this program?
Do you have any concerns about this program? We would like to reiterate that strict confidentiality governs all data sharing within this program.
Would you like to be a mentor or a buddy?
Mentor
Buddy
Not Sure!
What mode of contact would prefer with a potential match? Check all that apply. For all types of contact, the participant is responsible for expenses that may be incurred (e.g. gas to drive, texting or internet charges, etc.)
Phone (Voice)
Email
Texting (phone numbers will be shared)
Video chat
In-person
May we share the information you have given us, as appropriate, with your potential match?
Yes
No
Would you like to volunteer your time to administer this program?
Yes
No
I may be interested
If yes, what is the one thing you have most to offer to this program?
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Submit
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