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 six two-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 6 week period. If you will miss more than 1 class, you may need to wait until a later class to participate.

* 1. First Name

* 2. Last Name

* 3. Phone Number

* 4. Email Address

* 5. Mailing Address

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

* 10. Age of person with mental health condition

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

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

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

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

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

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

* 20. Additional comments: