PDPH Virtual Peer Support Group for Loss due to Substance Use

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Thank you. If you have questions, please contact Laura.Vargas@Phila.Gov

Email *

First and Last Name *

Best phone number to reach you at (contact information will not be shared with anybody other than the facilitator) *

Please select your availability for future groups *

Every other Tuesday, 6:30 - 8:00 pm (currently running)

Weekday mornings (between 9 and 12)

Weekday afternoons (between 12 and 3)

Weekday late afternoons (between 3 and 6)

Thursday evenings (between 5 and 8)

I need to talk to talk to the facilitator about scheduling

Required

Age category *

18-24

25-34

35-44

45-54

55-64

65-74

75+

Home zip code

Please share with me briefly about the person whose loss you are grieving (name, relationship to the individual, approximate date of death, and any additional information you feel comfortable sharing at this time)

How did you find out about the group?

How comfortable are you with being in a support group with people who are in recovery or using drugs? *

I am comfortable with this.

I am nervous about it, but willing to try!

I am against it and worried that it may affect my healing process.

I would like to speak to the facilitator about this.

I understand that in support groups, members will be expected to uphold each other's confidentiality. I understand that all information disclosed within session is confidential and may not be revealed by me about other members. *

Yes, I understand and agree.

I understand that If I am a danger to myself or others, the facilitator is mandated by law to break confidentiality to report that danger to authorities and refer to the appropriate level of care. This includes disclosures of suicidal thoughts, homicidal thoughts, and abuse. Contact facilitator if you'd like more information about mandated reporting. *

Yes, I understand and agree.

I understand that if I am presenting with mental health symptoms that need more care than a support group can provide, the facilitator will discuss this individually with me outside of the support group to assist in referring me to the appropriate treatment. *

Yes, I understand and agree.

Attendance is optional, but I understand that support groups work best with active and consistent participation. Participants should make efforts to be on time. A spot in group cannot be held for individuals who miss three consecutive sessions without notifying the facilitator. *

Yes, I understand and agree.

I have access to technology that allows me to join in a confidential location, where others are not able to listen in on or watch the group meeting. *

Yes, I have a private space in which to participate

Yes, I have earbuds and/or headphones that allow me to participate confidentially

I would like to discuss this with the facilitator

Required

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