Register for Family-to-Family in January

Name*

First Last

Preferred Method of Communication*

Phone
Email
Text

Phone*

Phone Type*

Cell
Home
Work

Is it okay to leave a message?*

Yes
No

Email*

Address*

Street Address City State ZIP Code

In which county do you live? (Hamilton, Clermont, Warren, etc.)*

Gender*

Male
Female
Non-binary/third gender
Prefer not to answer

Age Group*

Ethnicity*

Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer

Race*

Education*

Are you a veteran receiving services from the VA?*

Yes
No

Are you a family member, legal guardian, household member, or caregiver of a veteran receiving services from the VA?*

Yes
No

How did you first hear about NAMI Family-to-Family?*

Do you have a family member or friend living with mental illness?*

Yes
No

Relationship to family member - they are your:*

Why are you interested in attending the class?*

What is/are your family member's diagnosis/diagnoses?*

If you choose other above, please specify:

How long has the individual been ill?

Is the individual currently in treatment with any of the providers listed? (Check all that apply.)*

Psychiatrist
Therapist
Primary Care
Not currently in treatment
Medication management
Case manager
Health homes
Public mental health services
Other

If you chose other above, please specify:

Emergency Contact Name*

First Last

Emergency Contact Phone*

How would you like to receive class materials?*

Email .pdf file
Mail
Pick-up from our Sharonville office

We would like to add you to our email list to keep you informed of other NAMI Southwest Ohio news and events. If you prefer not to be added, please check below.

I do not wish to be added to your email list.

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NAMI Family-to-Family Registration: Zoom, January 25, 2021

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