Registration Form for Peer to Peer

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

All applicants must complete this form prior to being placed in a Peer to Peer class.

Email *

First Name *

Last Name *

Email address *

Phone number *

I am registering for the following class. *

The October Class is FULL. THERE ARE NO MORE SPACES LEFT IN THIS CLASS!!!

The November Class is FULL. THERE ARE NO MORE SPACES LEFT IN THIS CLASS!!!

Tentative dates of November 28 to December 20 on Saturday and Sunday from 1-3

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 Peer-to-Peer 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? *

Yes

Eight sessions over 4 weeks 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 Peer to Peer 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 Peer to Peer 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.

Required

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 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 and identify as having a mental illness. *

Yes

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

Please provide us with the name and phone number of an emergency contact person. *

For the purpose of distributing books/materials for this class, please list the city and state in which you live. *

Are you a veteran? *

Yes

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms