Register for Peer-to-Peer in Western Hills Talbert House 4968 Glenway Avenue Cincinnati, OH 45238 Map and Directions Tuesdays, March 21 – May 23 1:00 PM to 3:00 PM NAMI Peer-to-Peer Registration: Western Hills Winter 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 9-12CollegeDo you have a military background?*YesNoAre you a family member, legal guardian, household member, or caregiver of someone with a military background?*YesNoHow did you hear about NAMI's Peer-to-Peer course?*Why are you interested in attending the class?*Have you been diagnosed with a mental illness?*YesNoWhat is your 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 have you had a diagnosis?Are you currently in treatment with any of the providers listed?PsychiatristTherapistPrimary careNot currently in treatmentMedication managementCase managerHealth homesPublic mental health servicesAre 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.