NAMI Peer Support Group Facilitator Application

Contact Val Lepoutre: 860 882-0236 or email vlepoutre@namict.org.

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* 1. Please provide your contact information:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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

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

NAMI Connection Recovery Support

NAMI Veteran Support

Online Connection Recovery Support

BIPOC Support

AANHPI Support

NAMI Rainbow Connection (LGBTQ2S+) Support

Other (please specify)

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* 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

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* 5. Please check any NAMI programs that you have completed:

NAMI Family to Family course

NAMI Family to Family Teacher training

NAMI Peer-to-Peer course

In Our Own Voice Presenter training

NAMI Connection Facilitator training

NAMI Basics course

NAMI Basics Teacher training

NAMI Ending the Silence Presenter training

NAMI SMARTS for Advocacy

NAMI Provider Education

NAMI Provider Education Panelist training

NAMI Homefront

NAMI Sharing Hope

NAMI Faithnet

NAMI Sharing Your Story with Law Enforecement

NAMI Young Adult Connection Community Facilitator training

Other (please specify)

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* 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

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* 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

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

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

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* 10. Availability to facilitate/co-facilitate NAMI Family Support Group (Check all that applies):

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning	Morning Monday	Morning Tuesday	Morning Wednesday	Morning Thursday	Morning Friday	Morning Saturday	Morning Sunday
Afternoon	Afternoon Monday	Afternoon Tuesday	Afternoon Wednesday	Afternoon Thursday	Afternoon Friday	Afternoon Saturday	Afternoon Sunday
Evening	Evening Monday	Evening Tuesday	Evening Wednesday	Evening Thursday	Evening Friday	Evening Saturday	Evening Sunday

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* 11. Do you have your own transportation?

Yes

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* 12. Are you willing to travel?

Yes

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* 13. If yes, how far:

5-10 miles

11-20 miles

More than 20 miles

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* 14. In what language do you speak most fluently?

Arabic

Armenian

Chinese

English

French

French Creole

German

Greek

Gujarati

Hindi

Italian

Japanese

Korean

Persian

Polish

Portuguese

Russian

Spanish

Tagalog

Urdu

Vietnamese

Other (please specify)

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

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

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

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

NAMI Peer Support Group Facilitator Application

Question Title

* 1. Please provide your contact information:

Question Title

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

Question Title

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

Question Title

* 4. Please check all that apply:

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* 5. Please check any NAMI programs that you have completed:

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

Question Title

* 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.)

Question Title

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

Question Title

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

Question Title

* 10. Availability to facilitate/co-facilitate NAMI Family Support Group (Check all that applies):

Question Title

* 11. Do you have your own transportation?

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* 12. Are you willing to travel?

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* 13. If yes, how far:

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* 14. In what language do you speak most fluently?

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

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

Question Title

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

Question Title

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

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

* 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.)

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