NAMI Family-to-Family Interest Form

Thank you for your interest in NAMI Family-to-Family! Please fill out this form to receive more information on the next available course.

NOTE: This course is for family and friends of adults 18 years old or older. If your family member is 17 or younger, please click here to add your name to the NAMI Basics wait list.

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

Family-to-Family (General): For any adult who identifies as living with a mental illness.
Family-to-Family for the African American & Black Community: For adults who live with a mental illness AND as a part of the African American and Black community.

Which course would you like to join?

Family-to-Family (General)Family-to-Family for the African American & Black Community

Page 2

Contact information

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

Are you Latino/Latina or Hispanic?

Your racial identity.

Please tell us what other race you identify as

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 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 Identity 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