Partner/Spouse Support Group Prospective participant registration form

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All information in this form will be accessible only to this group facilitators and kept strictly confidential. After submitting your form the group facilitator will reach out to you to confirm your admittance to the group and provide you with the ZOOM meeting link. Both audio and video connection are required for quality support group experience.

Email *

Do you provide care to your partner/spouse affected by mental health condition? If not, this group is not suitable for your needs. Please seek other support group. *

Yes

Required

Please provide your name *

Please provide your email address *

Please provide your street address *

Please provide your phone number *

Please provide third party emergency contact information - phone number

What is your loved one diagnosis (optional)

What is your main concern? (optional)

How did you find out about NAMI Family Support program?

family member or friend

health care provider

NAMI Mass website: namimass.org

NAMI publication

NAMI local affiliate website

local newspaper or advertisement

NAMI Mass News You Can Use weekly electronic bulletin

Other:

Are you willing and able to adhere to strict confidentiality policy related to any personal information shared during group meetings? *

Yes

Required

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