In Our Own Voice Presenter Application Survey

1.Please provide your contact information below:(Required.)

Full Name

NAMI Affiliate

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Primary Phone Number

2.What is your age?

3.Do you have a NAMI membership? If you are not a current NAMI member, you must become one prior to the training. Memberships are available starting at $5. Click here to become a member.

Yes

No

Unsure

4.If yes, which email is connected to your NAMI membership/login?

5.Have you seen an In Our Own Voice (IOOV) Presentation?

Yes

No

Unsure

6.Have you attended other NAMI courses or classes? If yes, please describe:

7.Are you a currently certified to teach/lead any other NAMI Signature Programs? If yes, please list:

8.Do you have access to a computer and Internet for this training?(Required.)

Yes

No

Unsure

9.Please Answer The Following Questions In 1-2 Sentences: Describe why you would like to become an In Our Own Voice presenter.

10.Describe your experience as a person with lived experience, and what recovery means to you.(Required.)

11.Describe your work/ volunteer experience and/ or qualifications to become a presenter.(Required.)

12.Presenter Requirements (please check off that you agree to all of the following requirements):(Required.)

I am a person with lived mental health experience.

I am or will become a NAMI member.

I understand that my participation in this virtual training does not guarantee that I will be certified as a presenter.

I will commit to meeting with the NAMI Connecticut staff and complete the required practice/training.

If certified, I will make every effort to deliver 3 presentations per year.

I will communicate promptly with the NAMI Connecticut state office, as requested or required, and will submit
all forms and data to the state and national offices, as required by an In Our Own Voice Presenter.

I agree to be a presenter for In Our Own Voice for a minimum of two years to help meet the needs of my
Affiliate.

I understand that IOOV Presentations are not intended to recommend or endorse specific medications or
therapies, but instead to educate and empower all audience members.

13.Is there anything else you'd like to share?

15.How did you hear about this program/ training?

16.What is your race or ethnicity?

Self-describe below:

18.Signature (by typing your name in the above box you confirm that all information in this application is true).(Required.)

19.Today's Date(Required.)

Date / Time

Date

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