NAMI Basics Interest Form

NAMI Basics is for parents and other family caregivers of children and adolescents who have either been diagnosed with a mental illness/emotional disturbance or who are experiencing symptoms but have not yet been diagnosed. This course consists of three five-and-a-half hour classes.

**Please note the time commitment required to participate in the NAMI Basics program. It is important that participants show up each week over the 3 week period. If you will miss more than 1 class, you may need to wait until a later class to participate.

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* 1. First Name

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* 2. Last Name

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* 3. Phone Number

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* 4. Email Address

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* 5. Mailing Address

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* 6. Are you the parent or guardian of an adolescent with mental illness or have a child who is exhibiting symptoms of mental illness?

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* 7. Will a spouse be joining you?

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* 8. If yes, what is their full name and email address?

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* 9. The person with a mental health condition is your:

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* 10. Age of person with mental health condition

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* 11. Types of mental health condition/behavioral difficulties (check all that apply)

ADHD

Anxiety/panic/phobia

Autism spectrum disorder

bipolar disorder

conduct disorder

eating disorder

major depressive disorder

OCD

oppositional/defiant disorder

schizophrenia

substance abuse

don't know

Other (please specify)

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* 12. This person lives with:

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* 13. Why do you want to participate in the NAMI Basics course?

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* 14. Are you able to make the time commitment to attend each class over the course of 6 weeks?

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* 15. What challenges do you currently face in seeking supports and services in the community for your loved one?

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* 16. Do you feel you can participate in a modeled or structured program? Do you understand the role of the facilitators is not to give medical advice to anyone participating?

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* 17. Are there any special needs or considerations we should know about when considering your application? (lack of transportation, handicapped, other limiting concerns)

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* 1. First Name

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* 2. Last Name

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* 3. Phone Number

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* 4. Email Address

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* 5. Mailing Address

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* 6. Are you the parent or guardian of an adolescent with mental illness or have a child who is exhibiting symptoms of mental illness?

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* 7. Will a spouse be joining you?

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* 8. If yes, what is their full name and email address?

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* 9. The person with a mental health condition is your:

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* 10. Age of person with mental health condition

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* 11. Types of mental health condition/behavioral difficulties (check all that apply)

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* 12. This person lives with:

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* 13. Why do you want to participate in the NAMI Basics course?

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* 14. Are you able to make the time commitment to attend each class over the course of 6 weeks?

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* 15. What challenges do you currently face in seeking supports and services in the community for your loved one?

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* 16. Do you feel you can participate in a modeled or structured program? Do you understand the role of the facilitators is not to give medical advice to anyone participating?

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* 17. Are there any special needs or considerations we should know about when considering your application? (lack of transportation, handicapped, other limiting concerns)

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* 18. Do you have your own transportation? If no, do you use public transportation?

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* 19. Do you feel comfortable reading out loud to others from written text?

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* 20. Additional comments: