Name:

Email address:

Telephone number:


Address:


City:

State:

ZipCode:

Country:


Best way to be contacted:
Email
Telephone
Initial phone call; email follow-up
No preference
If by phone, what is the best time to reach you?

The following questions will help us try to match you with a support person who has had a similar experience to you, and is possibly at a similar life stage. If you don’t have very much information about the situation yet, that is fine, just answer whatever you can.

1. What is your relationship to the person with the cavernous angioma/angiomas? Is it your child, spouse, friend, etc.?


2. When was this person diagnosed with a cavernous angioma/angiomas?


3. Do they have:
a solitary angioma
multiple angiomas

If a solitary angioma, where is it located?


If multiple angiomas, do you know where the symptomatic angiomas are located?


4. Have they had surgery or are they contemplating surgery? If not, have they been advised that surgery is not the best option for their angioma/angiomas or that it is currently inaccessible?


5. What symptoms have they experienced as a result of the angioma/angiomas? Have the symptoms resolved or are some ongoing?


6. Do they have seizures?
Yes
No

7. What are some challenges you face in being a parent and/or caretaker of this person?



8. Personal Information:

What is the age of the person with the angioma/s?


If you are a parent of a child with cavernous angiomas, do you have other children? If so, how many and what ages?
Yes
No


Some people rely heavily on their spiritual beliefs during difficult times. If this is true for you, would you prefer a peer partner with a similar religious background? If so, what is your religious background?


Are there any other factors you would like us to consider when matching you with a peer partner?


I understand that Angioma Alliance peer support is not a substitute for obtaining competent medical advice. Furthermore, I understand that although Angioma Alliance has tried to establish many safeguards, Angioma Alliance cannot be held liable for any injury that occurs as a result of the peer partner program.

Thanks for sharing your information. We will do our best to match you with a Peer Partner that can be helpful in supporting you through this difficult time.