Loved Ones Impacted By Problem Gambling Support Group
Led by VPGH Network Clinician Tammy Muir and VPGH CPRS Lisa Cochran
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
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, the 1st and 3rd Wednesday each month 6:30-7:30pm. 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: