Individual Peer Support

Individual Peer Support volunteers are connected to others in the lupus community on an add needed basis. Sign up to offer support, receive support or both on this form.

Name*
First Last
I am looking to*
- Take advantage of the LSI's Individual Support Program
- Volunteering to support LSI's Individual Peer Support Program
- Both
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
I prefer to be contacted by*
- Phone
- Email
- Either
Age*
Please enter a number from 18 to 100.
What is your connection to lupus? (check all that apply)*
- I have lupus
- I am the spouse of someone with lupus
- I am the child of someone with lupus
- I am the parent of someone with lupus
What type of lupus do you or your lupus connection have?*
- Select All
- SLE
- Discoid
You (or someone you care about with lupus) has or has had lupus involvement with
- Select All
- Kidneys
- Central Nervous System
- Blood
- Stroke
- Heart attack
- Joints
- Other organ involvement
Please include any information you feel would be helpful in matching you with a volunteer or participant.
Consent*
I agree for LSI to facilitate sharing my contact information with another member of the lupus community for Individual Peer Support purposes. This activity is for support purposes only and serve to benefit LSI’s mission. The Lupus Society of Illinois (LSI) and our Individual Support volunteers do not provide medical advice or recommendations. This activity should not substitute or replace expert medical care. Before making changes to your medical care, consult your qualified healthcare professionals familiar with your medical condition and health status.