Register for Family-to-Family in January Register below for our Family-to-Family class being held via Zoom. Mondays, January 25 to March 15, 2021, 6:30 PM to 9:00 PM EST NAMI Family-to-Family Registration: Zoom, January 25, 2021 Name* First Last Preferred Method of Communication*PhoneEmailTextPhone*Phone Type*CellHomeWorkIs it okay to leave a message?*YesNoEmail* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code In which county do you live? (Hamilton, Clermont, Warren, etc.)*Gender*MaleFemaleNon-binary/third genderPrefer not to answerAge Group*18-2425-3940-5556-6465+Ethnicity*Hispanic or LatinoNot Hispanic or LatinoPrefer not to answerRace*American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderMultiracialWhite/CaucasianEducation*Less than high school degreeHigh school degree or equivalent (eg GED)Some college but no degreeAssociate degreeBachelor degreeGraduate degreeDoctorateAre you a veteran receiving services from the VA?*YesNoAre you a family member, legal guardian, household member, or caregiver of a veteran receiving services from the VA?*YesNoHow did you first hear about NAMI Family-to-Family?*Word of Mouth (such as a Friend or Family Member)Referral (Provider or other professional)NAMI Southwest Ohio WebsiteNAMI Southwest Ohio NewsletterNAMI Southwest Ohio Info & Referral HelplineNAMI Southwest Ohio Support Groupnami.orgOther NAMI ProgramOther NAMI AffiliateChurch or Community GroupFlyer, Brochure, or other PublicationInternet or Online SearchSocial MediaDo you have a family member or friend living with mental illness?*YesNoRelationship to family member - they are your:*Child (17 or younger)Child (18 or older)Step-child (17 or younger)Step-child (18 or older)ParentPartner or SpouseSiblingGrandchildNiece or NephewAunt or UncleIn-lawFriendWhy are you interested in attending the class?*What is/are your family member's diagnosis/diagnoses?* Anxiety Disorders - Generalized, Social, or Phobias Attention Deficit Hyperactivity Disorder (ADHD) Autism Spectrum Disorders Bipolar Disorder - any type Borderline Personality Disorder Depression - Major, Persistent, Seasonal, Other Dissociative Disorders Eating Disorders Narcissistic Personality Disorder Obsessive-Compulsive Disorder (OCD) Panic Disorder Paranoid Personality Disorder Post-Traumatic Stress Disorder (PTSD) Psychosis (unspecified) Schizoaffective Disorder Schizophrenia Substance Use Disorder - including Alcohol Use Disorder Unknown Other 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 fileMailPick-up from our Sharonville officeWe 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.