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, please 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.

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	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

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

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