NAMI Southwest Iowa Thursday Connection Form

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Thursday Connection Meeting 6:30 - 8:00 PM (if you'd like to participate during a different day and time, please specify that in the last question of this form)

Email *

Your Name *

Your Address

Your phone number *

Your emergency contact *

Emergency contact number *

Have you attended a support group before?

Yes

Yes, I have attended a NAMI support group in the past

Other:

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All NAMI support group members must be 18 years or older *

I am 18 years old

I am under the age of 18 but would like a referral

The Zoom platform we will be using will be a private meeting, however it is not HIPPA approved and NAMI SW Iowa cannot guarantee confidentiality of information you share during the support group meetings held virtually. *

I understand and would still like to participate

I no longer want to participate but would like information for HIPPA approved, individual counseling services from a professional provider

I would like more information on this issue before participating

Anything else you'd like the organizer of this support group to know about you? If you have specific questions you can also enter them here.

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