NAMI Peer-to-Peer Interest Form

Thank you for your interest in NAMI Peer-to-Peer! This course is for adults who are living with a mental illness.

NOTE: We have three versions of this course. Please read the description of each and select the one most relevant to you.

Peer-to-Peer (General): For any adult who identifies as living with a mental illness.
Peer-to-Peer LGBTQ+: For adults who live with a mental illness AND as a part of the LGBTQ+ community.
Peer-to-Peer Young Adults: For adults who identify as living with a mental illness AND are between the ages of 18 and 30.

Which course would you like to join?

Peer-to-Peer (General)Peer-to-Peer LGBTQ+Peer-to-Peer Young Adults

Contact information

First name

Last name

What is your preferred phone?

Landline (home)Mobile

Landline (home)

Mobile

Email address

What is your preferred contact method? (optional)

Phone
Email

How did you hear about us?

Please select how you heard about this course.

Demographic information helps us get funding, so we can keep our programs FREE for those who need them. This information also helps us develop new programs that serve all community members. Your answers are confidential.

Your street address

City

State

Zip code

Please enter first 5 digits only

Your date of birth - use M/D/YYYY format

Your racial identity

Please describe your racial identity

Are you Latino/Latina or Hispanic?

What is your Primary Language - the language that you use most frequently to communicate with?

Please tell us your primary language

Your gender

Your sexual orientation

ADHD	Anxiety/Panic Disorder
Bipolar Disorder	Borderline Personality Disorder
Delusions	Depression
Dissociative Disorder (other than Dissociative Identity Disorder)	Dissociative Identity Disorder
Major Depressive Disorder	Mania
Mood Disorder (other than depression, Bipolar or Disruptive Mood Dysregulation Disorder)	Obsessive Compulsive Disorder
Paranoia	Personality Disorder
Psychosis	Schizoaffective
Schizophrenia	Suicide Ideation
Trauma/PTSD	Undiagnosed

ADHD	Aggression
Anger Issue	Anxiety
Behavioral Issue	Delusions
Depression	Disruptive Mood Dysregulation Disorder
Dissociative Disorder	Isolation
Mania	Mood Disorder (other than depression, Bipolar or Disruptive Mood Dysregulation Disorder)
Obsessive Compulsive Disorder	Oppositional Defiance Disorder
Paranoia	Personality Disorder
Psychosis	Self-harm
Suicide Ideation	Trauma/PTSD

Addiction - Alcohol	Addiction - Substance
Addiction - Other	Asperger Syndrome
Autism (not a mental illness)	Bereavement
Cognitive Disorder	Dementia
Developmental Disorder (other than Autism, Aspergers)	Eating Disorder
Learning Disability	Physical Abuse
Psychological Abuse	Sexual Abuse
Abuse - Other	Sleep Issue/Disorder
Other