NAMI Basics Interest Form
Contact information
Thank you for your interest in NAMI Basics!
Please fill out this form to receive more information on the next available course.
NOTE: This course is only for parents and other caregivers of children 17 years old or younger.
If your family member is 18 or older
, please
click here to add your name to the NAMI Family-to-Family wait list
.
First name
Last name
What is your preferred phone?
Landline (home)
Mobile
Landline (home)
Mobile
Email address (
If you are registering on behalf of someone else, p
lease provide
their
unique 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.
Please select...
ACS
NAMI-NYC Class
NAMI-NYC Helpline
NAMI-NYC Support Group
NAMI-NYC Website
NAMI-NYC Newsletter
NAMI-New York State Newsletter
Internet Search
Word of Mouth/Family or Friend
Social Media
Service Provider
1199
Other
Unknown/Undisclosed
Prefer Not to Answer
Your relationship
Who has a diagnosis? They are my:
Please select...
Child
Foster Child
Grandchild
Sibling
Step Child
Other Family Member
The child
Child's date of birth
- use M/D/YYYY format
Please use "m/d/yyyy" format
Age when symptoms began
Does the child have a diagnosis?
Yes
No
Primary diagnosis or symptoms of the child.
Please check all that apply as
primary
conditions.
ADHD
Anxiety/Panic Disorder
Bipolar Disorder
Borderline Personality Disorder
Delusions
Depression
Dissociative Disorder (other than Dissociative Identity Disorder)
Major Depressive Disorder
Mania
Mood Disorder (other than depression or Bipolar Disorder)
Obsessive Compulsive Disorder
Oppositional Defiance Disorder
Paranoia
Personality Disorder
Psychosis
Schizoaffective
Schizophrenia
Suicide Ideation
Trauma/PTSD
Undiagnosed
What other challenging symptoms or conditions does the child experience?
Please check all that apply as
other
challenging conditions.
ADHD
Aggression
Anger Issue
Anxiety
Behavioral Issue
Delusions
Depression
Disruptive Mood Dysregulation Disorder
Dissociative Disorder
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
Relevant medical, developmental, trauma conditions.
Please check all that apply.
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
Other relevant medical, developmental, behavioral conditions or trauma
Does the child have an Individualized Educational Plan (IEP)?
Yes
No
Unsure
Is the child in treatment?
Yes
No
What kind of treatment?
Therapy
Medication
Other
Has the child been hospitalized for a psychiatric condition
in the past year
?
Yes
No
For how long was the child hospitalized?
Where does the child currently live?
Please select...
Family Residence
Foster Care
Group Home
Shelter
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
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
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Hawaii
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New Hampshire
New Jersey
New Mexico
New York
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip code
Please enter first 5 digits only
Your date of birth - use M/D/YYYY format
Your racial identity
Please select...
Alaskan Native/American Indian/Native American
Asian
Black/African American
Hawaiian or Pacific Islander
White
Mixed Race
Other
Prefer not to answer
Please describe your racial identity
Are you Latino/Latina or Hispanic?
Please select...
Yes
No
Prefer not to answer
What is your Primary Language - the language that you use
most frequently
to communicate with?
Please select...
English
Spanish
Cantonese
Mandarin
Russian
Other
Please tell us your
primary l
anguage
Your gender
Please select...
Woman
Man
Transgender Woman
Transgender Man
Non-Binary
Gender Non-Conforming
Other
Prefer not to answer
Your sexual orientation
Please select...
Heterosexual
Lesbian
Gay
Bisexual
Pansexual
Asexual
Other
Prefer not to answer
Contact Information