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.



1.First Name
2.Last Name
3.Phone Number
4.Email Address
5.Mailing Address
6.Are you the parent or guardian of an adolescent with mental illness or have a child who is exhibiting symptoms of mental illness?
7.Will a spouse be joining you?
8.If yes, what is their full name and email address?
9.The person with a mental health condition is your:
10.Age of person with mental health condition
11.Types of mental health condition/behavioral difficulties (check all that apply)
12.This person lives with:
13.Why do you want to participate in the NAMI Basics course?
14.Are you able to make the time commitment to attend each class over the course of 6 weeks?
15.What challenges do you currently face in seeking supports and services in the community for your loved one?
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?
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: