Survey - SED HydrocephalusCONNECT Phone Request

Hydrocephalus CONNECT

A hydrocephalus diagnosis can be overwhelming.
A new challenge in your hydrocephalus journey can be difficult to manage.
Every experience with hydrocephalus is unique, and we want to connect you with someone who has ‘been there’ in a situation that is similar to yours.

Through our HydrocephalusConnect program you will be matched with trained Peer Support Volunteers based upon diagnosis, age, gender, relationship to hydrocephalus (patient, caregiver, parent, etc.), complications and/or comorbidities and other factors.

HA Peer Support Volunteers are ready to:
-Listen with compassion
-Share their experience
-Provide basic information about hydrocephalus
-Connect you with valuable information about HA and other resources available to help you and/or your loved one live fully with hydrocephalus!

To get connected with an HA Peer please complete the Form below and your HA Peer will reach out to you very soon!

HA Peer Connect Form:

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Question - Required - What is your connection to the Hydrocephalus Association?

Question - Not Required - Hydrocephalus Type

Question - Not Required - Patient Diagnosed Age

Question - Not Required - Primary Cause of Hydrocephalus

*

Question - Required - Current Primary Treatment

ETV

ETV & CPC

No Treatment

Shunt

Shunt and ETV

Question - Not Required - Primary Shunt Type

VA (Heart)

VP (Abdomen)

LP (Spine)

VPL (Lung)

Question - Not Required - Comorbidities (select the primary comorbidity)

Alzheimer's Disease

Autism Spectrum Disorder

Cerebral Palsy

Chiari Malformation

Diabetes

Epilipsy or Seizures

Parkinson's Disease

Spina Bifida/Myelomeningocele

Urinary Incontinence

Visual Impairment

Other

None

Question - Not Required - Complications (select all that apply)

	Anxiety
	Attention Disorders (ADD/ADHD)
	Clumsiness (Dyspraxia)
	Depression
	Developmental Delays (reaching milestones)
	Executive Function Disorder
	Intellectual Disability
	Language Delay (problems understanding language)
	Learning Disability (inc. NVLD)
	Multiple Shunts
	Physical Impairment
	Short Term Memory Problems
	Speech Delay (problems getting words out)
	Tics
	Tremors
	Unknown/Unsure
	None of the Above

Question - Not Required - What is the patient's date of birth?

Month

Day

Year

Please provide your name, phone and zip code (it will help us find you a peer in your area):

*

Name:

First Required	Last Required

*

Email: Required

*

ZIP / Postal Code:

Phone Number:

Yes, I would like to receive postal mail from Hydrocephalus Association

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