Register for Family-to-Family in Batavia Mercy Health—Clermont Hospital 3000 Hospital Dr. Batavia, OH 45103 Map and Directions Tuesdays, April 18 through July 11, 2017 6:30 PM to 9:00 PM NAMI Family-to-Family Registration: Batavia Spring 2017 Name* First Last Preferred Method of Communication*PhoneEmailMailPhone*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?*Gender*MaleFemaleAge Group*18-2425-6465+Race/Ethnicity*White (non-Hispanic)Black (non-Hispanic)AsianPacific IslanderHispanicMultiracialNative AmericanHighest Level of Education Completed*Education 9-12CollegeAre 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 hear about NAMI's Family-to-Family course?*Do you have a family member or friend living with mental illness?*YesNoWhat is your relationship to the individual living with mental illness?*SpouseParentStepparentFoster ParentGrandparentAdult ChildIn-LawSiblingFriendMental Health Care ProviderWhy are you interested in attending the class?*What is the primary diagnosis?AgoraphobiaAnxiety DisordersAttention Deficit Hyperactivity DisorderAutism Spectrum DisordersBipolar DisorderBorderline Personality DisorderCommunication DisordersDependent Personality DisorderDepressionDevelopmental DisordersDissociative DisordersEating DisordersNarcissistic Personality DisorderObsessive-Compulsive DisorderPanic DisorderParanoid Personality DisorderPost-Traumatic Stress DisorderPsychosis (Unspecified)Reactive Attachment DisorderSchizoaffective DisorderSchizophreniaSeasonal Affective DisorderSensory Processing DisorderSubstance Dependence and AddictionTourette's SyndromeHow long has the individual been ill?Is the individual currently in treatment with any of the providers listed? (Check all that apply.)PsychiatristTherapistPrimary careNot currently in treatmentMedication managementCase managerHealth homesPublic mental health servicesEmergency Contact Name* First Last Emergency Contact Phone*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.