Needs, Deliveries and Permissions
It takes all of us stepping up to support and connect with each other on the days when we're strong, so that someone else can do it for us on the days when we're not. Let your community know how we can help you here.
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address (or nearby intersection)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you have NOT filled out the SeekHealing Program Registration, please answer questions 1-16. Otherwise skip down to the "Volunteering" Section
Pronouns
he/him/his
she/her/hers
they/them/their
Other
Can we know if you are: (check all that apply)
Black
White
Asian
Hispanic
Native American
Other race
LGBTQIA+
Mobile-impaired
Visually-impaired
Non-hearing
Chronically ill
Under 18 years old
Other
May someone contact you via phone or email to check in with you?
Yes
No
Please text me the person's name and phone number first
May someone bring you things or leave things for you at your address?
Yes
No
Please text me the person's name and phone number first
Check the things that could be helpful to you:
Kind-word texts or emails
Check-in Calls and conversations. State below how many a week would benefit you.
Partner Pair: Connect 1:1 to listen and be listened to
Lyft rides to get to meetings or events
Help with Errands or daily tasks
Harm Reduction Kit including Narcan (naloxone)
Gifts for Cheer
Mediation or Clearing Conversation with someone you're having conflict with (professionally facilitated)
Free meal delivery
CP Buddies: pair up to go to a meeting or event with someone
Support Circle: a small group that meets exclusively to emotionally support you (professionally facilitated)
Herbal First Aid Kit for Anxiety, Stress and Detox
Handwritten Notes or Snail Mail
Seeker Services: acupuncture, herbal support, bodywork, energy healing, etc (limited availability)
Fentanyl test strips
Other
Please add any additional questions, comments or concerns you may have about receiving the above services.
Is there any other support you need?
Is there anything we should know in order to better serve you and support you in your self-care?
i.e., would you prefer not to connect with a male, or a female? Is there anything that triggers you that we should avoid doing or saying, or what's the best thing someone can do for you when you're in an emotionally-activated state.
Submit
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