NAMI Lane County Family to Family Pre-Survey

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NAMI Lane County Family to Family Pre-Survey

Thank you participating in NAMI Family-to-Family and taking the time to share your feedback. Your comments and suggestions will help improve the program. This data is used solely to report to funders in aggregate. No personal identifying information is stored or shared.

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* Indicates required question

First Name *

Your answer

Last Initial *

Your answer

Email *

Your answer

How were you referred?

Your answer

If in Lane County, what city do you reside in?

Your answer

Date *

MM

/

DD

/

YYYY

Are you or your family member an OHP (Oregon Health Plan) member?

Yes, Trillium

Yes, PacificSource

No

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