Adolescent Support Group Registration Form (NAMI Philadelphia)
NAMI Philadelphia's Adolescent Support Group is open to anyone between the ages of 12-17 with signed permission from a parent/guardian.

Permission slips can be found here: PERMISSION SLIP. Please have a signed printed or digital copy for the facilitators before the participant's first group attendance. Facilitators are Aikhees Ponton (aponton@namiphilly.org) and John Pillar (jpillar@bdo.com).

The group will meet on Wednesdays from 5 pm-6 pm* in the Scattergood Building of Friends Hospital (4641 Roosevelt Blvd, Philadelphia, PA 19124). 

For additional questions, you may contact Schimen Scott (Education and Training Manager) at schimenscott@namiphilly.org or Lexie Taylor (Youth and Advocacy Manager) at LTaylor@namiphilly.org.

*Some groups may extend to 6:30 pm if needed.
Participant Name *
Participant Age *
Participant Gender
Participant Pronouns
Participant Parent/Guardian Name *
Participant Parent/Guardian Phone Number
 *
Participant Parent/Guardian Email
 *
How did you hear about this group?
Clear selection
Why are you/the participant interested in attending?
What do you/the participant hope to obtain out of this group?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of NAMI Philadelphia. Report Abuse
Google Forms