NCHS Interest Form

NAMI on Campus High School - Interest Form

Hello and thank you for your interest in NAMI on Campus High School (NCHS)! We are excited that you're taking the next step in forming a club. NCHS is a NAMI California created program and is only supporting high schools within California.

Please complete the following form so we have some basic info about you and your school to get us started. Our team will be in touch within 3-5 business days of receiving your form to get you going on the next phase of club formation.

If you have any questions, please feel free to reach out to us- we are here to help! Please email NCHS@namica.org or call (916)567-0163.

Thank you!

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* 1. Your First Name

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* 2. Your Last Name

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* 3. Email Address

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* 4. School Name (No acronyms, please)

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* 5. School District

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* 6. School Address

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* 7. City

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* 8. Zip Code

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* 9. County (Specific region within the state)

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* 10. I am a:

Student

School Faculty/Staff Member

Other (please specify)

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* 11. Name of the adult advisor who will help lead the club

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* 12. Advisor's Email Address

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* 13. Advisor's Phone Number

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* 14. Advisor's title or role on campus:

School Nurse

Guidance Counselor

Social Worker

Psychologist/Mental Health Counselor

Teacher-of a topic not related to mental health

Teacher-of a mental health topic (psychology, health, etc.)

Other (please specify)

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* 15. Please select all that apply. The advisor:

Has lived experience of mental illness (either themself or a loved one lives with a mental illness)

Works with people directly impacted by mental illness

Has an educational degree in a mental health related field (psychology, social work, etc.)

Is a member of their local NAMI

Has taken one or more trainings on mental health (such as Mental Health First Aid, PBIS, etc.)

Has no experience in mental health

Other (please specify)

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* 16. Is your school part of the Cal HOSA program?

Yes

Not sure

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* 17. Have you been in contact yet with your local NAMI Affiliate about your interest in starting a NAMI on Campus High School Club?

Yes

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* 18. If you have connected with a NAMI Affiliate, please provide their following information:

NAMI Affiliate (NAMI _______)

Name of contact person

Contact person's email

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* 19. Is there a mental health club already on your campus?

Yes, and we will be merging that club with the NCHS club

Yes, but it has different goals than what we plan to do with NCHS, so they will stay separate

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* 20. Please check here if your school is registered to attend a NCHS in-person training.

Yes, our school is registered to attend a training

No, we are not attending a training

No, but I am interested to have a training held within our school district

No, I am NOT interested to have a training held within our school district

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* 21. How did you find out about the NAMI On Campus High School Program?

NAMI California Website

NAMI California Social Media

My Local NAMI Affiliate

NAMI California Program Info Session

NAMI California Event

NCHS Townhall

California Department of Education Event

A friend/family member/ co-worker/ teacher

Other (please specify)

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* 1. Your First Name

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* 2. Your Last Name

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* 3. Email Address

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* 4. School Name (No acronyms, please)

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* 5. School District

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* 6. School Address

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* 7. City

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* 8. Zip Code

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* 9. County (Specific region within the state)

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* 10. I am a:

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* 11. Name of the adult advisor who will help lead the club

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* 12. Advisor's Email Address

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* 13. Advisor's Phone Number

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* 14. Advisor's title or role on campus:

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* 15. Please select all that apply. The advisor:

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* 16. Is your school part of the Cal HOSA program?

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* 17. Have you been in contact yet with your local NAMI Affiliate about your interest in starting a NAMI on Campus High School Club?

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* 18. If you have connected with a NAMI Affiliate, please provide their following information:

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* 19. Is there a mental health club already on your campus?

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* 20. Please check here if your school is registered to attend a NCHS in-person training.

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* 21. How did you find out about the NAMI On Campus High School Program?

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* 22. Please let us know any comments or questions you have about NCHS and the process to forming a club