Screen Reader Mode Icon

Question Title

Registration and Qualifying Questionnaire
Thank you for your interest in becoming an American Chronic Pain Association (ACPA) Facilitator. Since 1980, the ACPA has offered peer support and education to people with pain. The ACPA offers pain management education, tools, family/caregiver support and opportunities for involvement in the development of chronic pain management and research. 

The American Chronic Pain Association facilitator and group resource has proven to have a great impact. Facilitators and their groups help with pain management and can improve a person’s quality of life. Group members have reported improvements not only with pain management but also with their family, friends, and co-workers.

We are here to help you start a peer-led support group. But first you must qualify. As an ACPA facilitator, you will oversee your own support group and will be a representative of the ACPA. If you are prepared to take on these responsibilities, and you feel prepared emotionally and physically to interact with a wide range of diverse individuals… then please proceed. You are required to share our mission and follow the group guidelines. Failure to do so will result in the discontinuation of your facilitator position. See if you qualify by answering a few questions.

Question Title

Facilitator Qualification Process:
This is the new official process of becoming and volunteering as an ACPA facilitator. All current and future facilitators must follow this process.

Question Title

Mission
The ACPA mission is two-fold: (1) to facilitate peer support and education for individuals with chronic pain and their families so that these individuals may live more fully in spite of their pain, and (2) to raise awareness among the health care community, policymakers, and the public at large about issues of living with chronic pain

Question Title

Please fill out your contact information (It will not be made public).

Question Title

Have you been convicted of a felony?

Question Title

What city/town and state are you wanting to start an ACPA Group?

Question Title

What would you name your chapter?

Question Title

The most common places to meet include churches, libraries, restaurant banquet rooms, government buildings, health clubs or gyms, coffee houses, city recreational centers, YMCA’s, pain clinics, therapist offices, hospital conference rooms, art museums, etc. Do you understand that ACPA groups do not meet at people’s homes?

Question Title

What type of place has agreed to host your group? (Put N/A if you are still looking for a place)

Question Title

What is the address of the place you will be facilitating a group?

Question Title

Do you understand that Groups are facilitated by a person with chronic pain.

Question Title

I understand that as an ACPA facilitator, I am willing to accept ALL responsibility for my group and wave all responsibility of the ACPA for my group interactions.

Question Title

I understand that all medical decisions should be decided between the person with pain and their healthcare provider.

Question Title

I understand that Groups are only intended to provide peer support in communities.

Question Title

I understand that guest speakers can be invited to speak on various topics of interest to your group, but the group cannot promote any specific type of physician, treatment, drug, procedure, or hospital.

Question Title

I agree to read and follow the ACPA Facilitator Guide and From Patient to Person.

Question Title

I agree to only use approved ACPA materials and will follow the ACPA Fundraising Policy.

Question Title

I agree to have people interested in joining my group contact me through the contact form on the ACPA website (your email address will not be made public).

Question Title

I agree to become a functioning representative of the ACPA and its mission.

Question Title

I agree to be patient, personable, understanding, compassionate, self-motivating, non-judgmental and friendly.

Question Title

I agree and will follow the ACPA Nondiscrimination/Anti-Harassment Policy.

Question Title

I understand that my group meetings will not be used for solicitation and will follow the ACPA Fundraising Policy.

Question Title

I agree to follow the ACPA Drug and Procedure Discussion Policy.

Question Title

What type of meeting do you prefer?

Question Title

How often do you plan to meet?

Question Title

What day of the week and what time do you plan to meet?

Question Title

Do you want ACPA business cards for your group? (You will be required to print)

( Privacy & Cookie Notice
0 of 27 answered
 

T