Register for Peer-to-Peer in Amelia Hope Community Center 4 Cecilia Drive Amelia, OH 45102 Map and Directions Saturdays, September 7 through October 26 1:00 PM to 3:00 PM NAMI Peer-to-Peer Registration Amelia 2019 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 Peer-to-Peer?*Word of Mouth (such as a Friend or Family Member)Referral (Provider or other professionalNAMI 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 MediaHave you been diagnosed with a mental illness?*YesNoWhy are you interested in attending the class?*What is your diagnosis/are your diagnoses?* Anxiety Disorders - Generalized, Social, or Phobias Attention Deficit Hyperactivity Disorder (ADHD) Autism Spectrum Disorders Bipolar Disorder - any type Borderline Personality Disorder (BPD) 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 Other 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?*YesNoWill you agree to keep confidential the disclosures of the other participants?*YesNoDo you foresee any attendance problems throughout the program?*YesNoIf 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.