Peer2Peer Partner Application Form

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First Name

Last Name

Phone

Birthdate

Gender

MaleFemaleOther

In what city do you live?

County

Do you speak a second language?

YesNo

What is your relationship to epilepsy?

I am a person with epilepsyI am a parent of someone with epilepsyI am a caregiver of someone with epilepsy

Highest Level of Education

Age of Child or Person being taken care of (if applicable)

I or the person I care for was diagnosed at the age of:

Birth0-1011-2021+

Cause

I or the person I care for has tried the following types of treatments

Please specify types of medication, surgeries, or other treatments.

I or the person I care for has struggled or is struggling with which of the following?

	Always	Frequently	Sometimes	Never
Difficulty with or in School
Social Issues
Driving
Personal Relationships
Stigma and Discrimination
Workplace Issues
Medication Side Effects
Depression or Anxiety
Age or Gender Specific Issues

What is the most important thing to discuss with your Mentor, if applicable?

What is the most important thing for my Mentor to know about me?

I want to be matched with an Mentor because...(Please provide a response below)

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