Ladies PG Peer Support Group
Fridays 7:30-8:30 PM
Name (please include your first name, last name initial is ok if you do not want to share your full last name):
*
First Name
Last Name
Email (use a valid email to receive the meeting link):
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about the group?
Counselor
Peer recovery specialist
VPGH
VCPG
Friend
Family
Online
Evive/app
Other
If "Other" was marked in the previous question, please specify:
Please mark all that apply:
I would like to be contacted to learn more about VPGH resources/services.
I am interested in counseling.
I am connected with a counselor through VPGH.
I am interested in peer recovery services.
I am already connected with a peer recovery specialist through VPGH.
Other
If "Other" was marked in the previous question, please specify:
This is a voluntary and confidential group. Group meetings will be held via Zoom, Friday 7:30-8:30p. The Zoom link will be shared prior to the next meeting and a reminder email will be sent weekly prior to the group. Please indicate you acknowledge and accept below.
I acknowledge and accept to be contacted via the email given within this form. I certify that this is an email I use and am not providing this information unknowingly for someone else.
Signature
(For Office Use Only) Meeting link has been shared:
Yes
No
Other
(For Office Use Only) Comments:
Approved for group attendance?
Yes
No
Submit
Should be Empty: