NAMI Provider Teacher Application

Question Title

* 1. Please enter your contact information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. Have you ever taken a NAMI education course?

Yes

Question Title

* 3. If yes to Q2, which courses have you taken (check all that apply)?

NAMI Basics

NAMI Family-to-Family

NAMI Peer-to-Peer

NAMI Homefront

Not applicable

Question Title

* 4. Are you a teacher/mentor for a NAMI education course?

Yes

Question Title

* 5. If yes to Q4, what NAMI education courses are a certified leader/teacher (check all that apply)?

NAMI Basics

NAMI Family-to-Family

NAMI Peer-to-Peer

NAMI Homefront

Not applicable

Question Title

* 6. Are you a program leader for any other NAMI Programs?

Yes

Question Title

* 7. If yes to Q6, which programs (check all that apply)?

NAMI Connection

NAMI Ending the Silence

NAMI In Our Own Voice

NAMI Family Support Group

NAMI Parents & Teachers as Allies

Not applicable

Question Title

* 8. Are you a member of NAMI Kansas?

Yes

Question Title

* 9. If yes to Q8, list the affiliate your are associated with (if no, enter N/A in the text box):

Question Title

* 10. Which of the following best describes you? (check all that apply)

I have a mental health condition

I am the family member of a person with a mental health condition

I am a mental health professional

Question Title

* 11. If you are a mental health professional, please tell us your professional role (i.e. nurse, therapist, direct care worker, social worker, etc.) and how long you have worked in this field. If not a mental health professional, enter N/A in the comment box.

NAMI Provider Teacher Application

Question Title

* 1. Please enter your contact information

Question Title

* 2. Have you ever taken a NAMI education course?

Question Title

* 3. If yes to Q2, which courses have you taken (check all that apply)?

Question Title

* 4. Are you a teacher/mentor for a NAMI education course?

Question Title

* 5. If yes to Q4, what NAMI education courses are a certified leader/teacher (check all that apply)?

Question Title

* 6. Are you a program leader for any other NAMI Programs?

Question Title

* 7. If yes to Q6, which programs (check all that apply)?

Question Title

* 8. Are you a member of NAMI Kansas?

Question Title

* 9. If yes to Q8, list the affiliate your are associated with (if no, enter N/A in the text box):

Question Title

* 10. Which of the following best describes you? (check all that apply)

Question Title

* 11. If you are a mental health professional, please tell us your professional role (i.e. nurse, therapist, direct care worker, social worker, etc.) and how long you have worked in this field. If not a mental health professional, enter N/A in the comment box.

Question Title

* 12. Please describe in 5-10 sentences why you would like to become a NAMI Provider Teacher?