Registration - Survivor Support Advocate

Survivor Support Advocate Application Form

You can save your progress at any time by clicking on the “Save Progress & Continue” button below

Step 1. Basic Information

First Name(Required)

Last Name(Required)

Email(Required)

This is the email address we will use to notify you when someone sends you an inquiry from your GNA profile page. For your privacy and security, GNA does not publish your email address to the public. It is important that you provide an email address you check regularly.

What condition, injury, illness, or disease have you experienced as a survivor?(Required)

Examples

Breast Cancer, Stroke, Amputation/Limb Loss, Meningitis, Sickle Cell Anemia, Multiple Sclerosis (MS) Post Traumatic Stress Disorder (PTSD), Lupus, Cystic Fibrosis, Sepsis, Traumatic Brain Injury, etc...

I have been trained and/or certified as a peer mentor.

Describe your training and/or certification.(Required)

I have experience leading or attending support groups.

Describe your support group experiences.(Required)

Provide any additional details about your personal journey or professional experiences that would benefit a survivor in need of advocacy support.

Other Services

Please select an additional service you offer, if applicable.

Medical Guidance

Wellness & Lifestyle

Insurance & Billing

Special Care & Aging

Choose Your Advocate Landing Page Name

All advocates have a unique page name on the directory. Your page name becomes part of the URL for your advocate profile:
https://gnanow.org/advocate/page-name

Examples

https://gnanow.org.advocate/john-smith-md
https://gnanow.org.advocate/dr-laura
https://gnanow.org.advocate/nurse-jackie

No spaces or special characters allowed. Please note that after you choose your page name you will NOT be able to change it.

Do not type "https://gnanow.org/advocate/" just the page-name you would like.

Step 2. Employment & Business Information

Business Name (optional)

Your affiliation with this business(Required)

I own this business

I am employed here

I am an Independent Contractor

I don't have a business

Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Current Work Phone Number(Required)

For your privacy and security, GNA does NOT publish your number to the public. Instead, GNA provides each advocate with their own unique, directory-specific number. When someone calls you from the directory, the call is forwarded to the number you provide here. Your current work mobile number is recommended.

Your Geographical Practice Area(Required)

Describe your geographical practice boundaries and restrictions

Do you offer TeleAdvocacy Services?(Required)

Yes

Do you offer a free initial consultation?(Required)

Yes

Step 3. Education & Training

Education and Advanced Degrees

Provide any secondary and/or advanced degrees.

Examples

Northern State University, Ph.D. Social Work, 1992
Sunshine County Community College, A.A.S. Communications, 1987
Sarah Wilson College, M.A. Public Health, 2004

Formal Education (optional)

Enter Your Formal Education

Training, Continuing Education and Memberships

Please list any additional information about your experience and abilities. This may include Accreditations, Certifications, Certificates & Memberships in relevant organizations. You can also include Volunteer Work, Service on Boards of Directors, Awards, Presentations or Publications.

Training, Continuing Education and Memberships (optional)

Enter Your Training, Continuing Education & Memberships

Step 4. How You Help Patients and Loved Ones

How you help patients and loved ones

This is the most important information you can provide to directory users. If you focus on a particular type of advocacy or if you’re seeking a particular type of client, you should specify that here. Concentrate on your strengths and explain, in a concise and informative manner, how you can help.

How you can help(Required)

Your patient advocate story

Every Patient Advocate has a reason for joining the profession. Here’s your chance to let the public know what inspired you to help others.

Your patient advocate story(Required)

Step 5. Additional Skills & Attributes

Additional Skills & Unique Attributes (Optional)

Please specify if you have any special knowledge, particular interests, and/or unique experiences that might appeal to patients and families who are considering your services. Examples may include your experience working with specific types of institutions like VA clinics or rehab facilities, your passion for a particular cause, or your familiarity with a condition, procedure, insurance company, or health system.

Additional Skills & Unique Attributes (optional)

Faith Experience (Optional)

If you have experience, insight, or understanding about specific religious customs, practices, or norms that could benefit someone searching for an advocate, please select any that apply.

Faith Experience

Catholicism

Christianity

Protestantism

Islamism/Muslim

Buddhism

Hinduism

Judaism

Atheism

Language Proficiency (Optional)

If you are fluent and comfortable communicating in any language(s) other than English, please be sure to mark any that apply below.

Language Proficiency

Profile Headshot Photo (Professional Quality Recommended)

Accepted file types: jpg, png, andgif, Max. file size: 128 MB.

Please do your part to maintain the integrity and perception of our profession by submitting a quality photograph of your head and torso. Please do not upload business logos, avatars, stock images, or photos depicting more than one person. Remember, quality headshots attract clients. Maximum file size allowed is 5MB. Acceptable file types are .jpg, .png, and .gif.