Register for Family-to-Family in Mason Christ’s Church at Mason 5165 Western Row Road Mason, OH 45040 Tuesdays, September 10 – November 26, 2019 6:30 PM – 9:00 PM Map and Directions Family-to-Family Registration - Mason Sept 2019 If you plan to attend with a family member or friend, please register each person separately. 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 equivalentSome 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 hear about the Family-to-Family course?*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 MediaWhich statement best describes you?*I am a person living with a mental health condition.I am a friend or family member of someone living with a mental health condition.Why are you interested in attending the class?*What is the primary diagnosis (if known)?* Anxiety Disorders - Generalized, Social, 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 Unknown Other If you chose "Other" above, please specify:Emergency 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.