NAMI Family Support Group Leader Application Survey

1.Please provide your contact information:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

2.What is the best day/time to contact you for an interview?

3.Which type of group do you wish to facilitate?

NAMI Family & Friends Support Group

NAMI CAN (Child Adolescent Network)

Online Family & Friends Support

Online NAMI CAN

Opioid Support Group (this requires additional training)

Other (please specify)

4.Please check all that apply:

I am a current NAMI Connecticut member

I am a person in recovery/person with lived experience

I am family member/friend of an adult (ages 18+) with mental health challenges

I am a family member of a child/adolescent with mental health challenges

I am a mental health advocate

I am a mental health professional or other healthcare provider

6.Please review (and check off) that you agree to meet NAMI's
Facilitator Requirements:

Willingness to undergo training and to adhere to fidelity to the NAMI Support Group Facilitator model

Commitment to begin to facilitate or co-facilitate a monthly NAMI support group within six months of the training

Commitment to communicate with NAMI Connecticut state office as requested or needed

Ability to provide group participant data to NAMI Connecticut as required

Willingness to identify potential new facilitators from support groups

Positive regard for, or personal experience with mutual support

Be or become a member of NAMI

7.Please provide a personal reference
(Please note: Your reference should be someone who knows you well enough to recommend that you be trained to become a facilitator.)

Name

Relation to You

Email Address

Phone Number

8.Have you ever been convicted of a felony?
If yes, please explain:

9.Please tell us why you want to be a NAMI Support Group Facilitator:

11.Do you have your own transportation?

Yes

No

12.Are you willing to travel?

Yes

No

13.If yes, how far:

5-10 miles

11-20 miles

More than 20 miles

15.SKIP - for in-person training only. Please specify any dietary restrictions or food allergies.

16.SKIP - for in-person training only. Please specify any accommodations you might need during the training.

17.I have read and understand the NAMI Support Group Facilitator position requirements. (please initial)

18.I understand that my attendance at Facilitator Training does not guarantee that I will be certified as a Support Group Facilitator. (please initial).