LDF Self-Help Group Application

If you would like your group to be listed with the LDF referral service, please complete the appropriate section below and send to:

Lyme Disease Foundation, One Financial Plaza, Hartford, CT 06103

Phone: 860-525-2000

Fax: 860-525-TICK (8425)

24-hr Hotline: 800-886-LYME (5963)

email: Lymefnd@aol.com

Benefits of Being An LDF Group

1. Be part of the world's largest and most influential organization dedicated to LD and other tick-borne disorders.
2. Have people on the same team in other parts of the country. All members of the team will be meeting the same standards of excellence in helping patients and their families.
3. Receive free information, including the newsletter . And, as a LDF S-H Group you may copy and distribute these to your group members.
4. Borrow LDF training materials and purchase support items at discounts.
5. Receive referrals from the LDF when people request a S-H Group in your area.
6. Benefit from the LDF staff assistance to your group. (Remember, we have a limited staff ! So, when talking to us summarize the situation and propose two or three potential solutions. Try to keep your call to less than 10 minutes.)
7. Make a positive impact in your community.
   

LDF S-H Group Guidelines

1. Key leaders are independent of any other LD group officer/directorship position. This prevents a co-mingling of liability. However, everyone is welcome to assist, attend, and support LDF support groups.
2. Group meeting are at a public place on a regular basis.
3. S-H Groups will not speak on behalf of the LDF without first clearing the issue with the LDF staff. This will help focus on essential messages. The more focused our message, the more likely the media, government, and others will "hear" what we say. While you may give your personal opinion, you must present it as such.
4. Adhere to the Guiding Principles.
   

Guiding Principles For LD S-H Groups

1. A Lyme Disease Self-Help Group's mission is to assist people who are adversely affected by Lyme disease or other tick-spread disorders help themselves to recovery. Groups carry the message of recovery to those who still suffer.
2. Group members are those people negatively affected by Lyme disease or other tick-spread disorders with a desire to help themselves or loved ones recover from suffering.
3. A group's mission is accomplished when members experience psychological recovery and can cope with life's "ups" and "downs."
4. Groups are informal and led by volunteers. Groups are led by ordinary people with extraordinary commitment. They do not substitute for professional help.
5. Groups use the shared leadership concept. This means that members share the responsibility for guiding the group.
6. Groups are self-supporting. Experience has shown that nothing can destroy a group's bond as quickly as disputes over money. However, member donations to cover the costs of copying, coffee, etc., are encouraged as a shared responsibility.
7. Groups recognize member privacy & confidentiality. Members attending meetings are assured confidentiality by other members.
8. Group members are responsible for their own decisions.
9. Group members who are "recovered" will consider donating their time to help the Lyme disease cause. This includes starting a Self-Help Group, being a mentor to someone who needs extra support, facilitating a meeting, or volunteering to conduct community education.

Self-Help Group Application Form

1. Self-Help Group Contact Information

   Mailing Address:
   C/O Name:
   Street Address:
   City :
   State:	Zip:
   Day Phone:	Night Phone:
   Fax:	e-mail:

2. Leadership Information

   Facilitator:
   Street Address:
   City :
   State:	Zip:
   Day Phone:	Night Phone:
   Fax:	e-mail:

   Co-facilitator:
   Street Address:
   City :
   State:	Zip:
   Day Phone:	Night Phone:
   Fax:	e-mail:

   Coordinator:
   Street Address:
   City :
   State:	Zip:
   Day Phone:	Night Phone:
   Fax:	e-mail:

   Co-coordinator:
   Street Address:
   City :
   State:	Zip:
   Day Phone:	Night Phone:
   Fax:	e-mail:

3. Meeting Information

   Meeting time: From to
   Meeting location:
   Frequency of meeting: (e.g. first Tue. of every month):
   Average attendance:
4. Are you interested in helping to establish other groups?
5. Are you available to speak to media? YesNo
6. Are you available to speak about your personal experience with LD? YesNo

   If yes, please attach (type or print) a brief description (100 words or less) of your LD experience and/or involvement with S-H groups.
   

We agree to abide by the LDF Self-Help Group Guidelines & Guiding Principles.

Facilitator signature:
Date:

Coordinator signature:
Date: