Family-to-Family Registration Form

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Family-to-Family Registration Form_2021

All applicants must complete this form prior to being placed on a Family-to-Family class list. If more than one family member is attending the class, please register each individual seperately. Thank-you.

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First Name *

Last Name *

Email address *

Phone number *

I am registering for the following class. *

Tentative dates of May 20 to July 8 on Thursday evening from 5:30 to 8 pm

Tentative dates of June 23 to August 11 on Wednesday evening from 5:30 to 8 pm

Tentative dates of August 7 - 29 on Saturday and Sunday from 1:00 - 3:30 pm

Tentative dates of September 13 to October 6 on Monday and Wecnesday from 5:30 to 8 pm

Tentative dates of October 2 to November 20 on Saturday from 10:00 am - 12:30 pm

I understand that, according to NAMI policy and for confidentiality reasons, I must be in a secure place with no one else around and must always remain visible on camera while this class is in session. *

Yes

Why are you interested in taking the Family-to-Family course? *

Do you agree to keep confidential the disclosures of other participants in the class? *

Yes

Do you agree to speak to others only of your own experiences as it relates to your family member or loved one? *

Yes

Eight sessions over a 4 week cycle is a substantial time commitment for a course. You are expected to attend each and every session. Do you foresee any attendance problems? If yes, please explain. *

The course material in Family-to-Family can be intensive, and it may be helpful to talk to a professional about some of your experiences in the class. Do you have a support system or person you can turn to? *

Yes

I will adhere to the following Family-to-Family guidelines: (Applicants must be willing to check all boxes to be considered for this class). *

I will attend ALL sessions of the class.

I will be on time to ALL class sessions.

I will attend all sessions with an open mind and open heart.

I will be courteous and respectful to program leaders and all other participants.

I will maintain the confidentiality of all participants.

I will NOT discuss personal information or topics outside the class.

I will look for the Information in the class that is the most helpful to me.

I am open to finding support from other individuals within the class.

必填

I understand that this is an education class and NOT a support group. *

Yes

I understand that I will be asked to share my story of my loved one's mental illness as one of the components of this class. *

Yes

I understand that, according to NAMI policy, one of the facilitators will contact me by phone prior to the start date for a pre-interview before my registration in the class can be finalized. *

Yes

I confirm that I am over 18 years of age (or 14 and over attending with a parent) and identify as having a family member or loved one with a mental illness. *

Yes

I am between 14 and 18 years of age attending with a parent

Is there any additional information that you need to let our facilitators know? If not, put "none." *

For the purpose of distributing books/materials and certificates upon completion of this class, please provide us with your complete mailing address. *

Are you a veteran? *

Yes

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