Individual Peer Support - Lupus Society of Illinois

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.