Wellness Call Registration Form

Wellness Call

This counselor led support group meets on the 2nd and 4th Tuesday of each Month and is for Virginia and West Virginia residents.
Name (please include your first name, last name initial is ok if you do not want to share your full last name):*

First NameLast Name
I reside in:*

VirginiaWest VirginiaOther
If other was marked in the previous question, please specify:
Email (use a valid email to receive the meeting link): *
example@example.com
Phone Number (not required):
Please enter a valid phone number.
How did you hear about the group?*

CounselorPeer recovery specialistVPGHVCPGFriendFamilyPGHNWVOnlineOther
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 resources/services in my state.I am interested in counseling.I am already connected with a counselor through VPGH.I am interested in peer recovery services.I am already connected with a peer recovery specialist through VPGH.I am already connected with a counselor through PGHNWV.I am already connected with a peer recovery specialist through PGHNWV.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 Zoom link will be shared prior to the next meeting. 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.
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