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 Name
Last Name
I reside in:
*
Virginia
West Virginia
Other
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.
Format: (000) 000-0000.
How did you hear about the group?
*
Counselor
Peer recovery specialist
VPGH
VCPG
Friend
Family
PGHNWV
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 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.
Group etiquette
Honor confidentiality
- what is shared in the group, stays in the group. Please do not record, screenshot, or repeat personal stories outside of the meeting.
Secure, private environment -
no outside observers, use headphones if there is potential someone could overhear
Listen without interrupting
- respect others when they are sharing
Allow time for others to share - practice active listening
Test equipment and internet connection ahead of meeting,
if possible
Minimize distractions
- turn off the TV or music, silence phone
Turn on your camera
- when possible, please join with camera to help build trust and a sense of community
I will do my best to honor the group etiquette above.
Signature
For Office Use Only:
Submit
Should be Empty: