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Peer to Peer Interest Form
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Email
*
Your email
Option 1
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First Name
*
Your answer
Last Name
*
Your answer
Street Address
*
Your answer
City/town
*
Your answer
Zip Code
*
Your answer
Phone
*
Your answer
Age
*
Your answer
What gender do you identify as?
Man
Woman
Transgender
Non-Binary/Non-Conforming
Prefer not to provide this information
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What race best describes you?
American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Pacisfic Islander
Black or African American
White
Prefer not to provide this information
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Do you have a diagnosed mental health challenge?
*
Yes
No
Required
If yes, what is your diagnosis?
Your answer
Are you currently on medication?
Yes
No
Do you see a mental health professional?
Yes
No
How did you hear about the Peer to Peer Education Program?
*
Flyer
Newspaper
Mental Health Porvider
Friend
Relative
Social Media
Email
NAMI Support Group
Other
I understand that this is an 8 session course and I am able to commit to all (most) of it.
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Yes
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Send me a copy of my responses.
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