Register for Peer-to-Peer via Zoom

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*

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 Peer-to-Peer?*

Have you been diagnosed with a mental illness?*

Yes
No

Why are you interested in attending the class?*

What is your diagnosis/are your diagnoses?*

If you chose other above, please specify:

How long have you had a diagnosis? (N/A if no formal diagnosis)*

Are you currently in treatment with any of the providers listed?*

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:

Are you comfortable talking with others in a group setting about having a mental illness?*

Yes
No

Will you agree to keep confidential the disclosures of the other participants?*

Yes
No

Do you foresee any attendance problems throughout the program?*

Yes
No

If yes, 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.

How would you like to receive your class materials?*

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

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NAMI Peer-to-Peer Registration: Zoom, Feb 2021

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