NAMI-NYC Family Match Interest Form

Our trained volunteers share their personal experience, coping, and hope as family members of someone living with mental illness. Your volunteer mentor will align with you in family role and familiarity with disordered behavior or diagnosis. They will reliably connect with you by phone twice per month over the next three months. Please reserve two hours per month to express your important needs and goals while loving someone with poor mental health. Please provide these details so we match you appropriately for one-to-one support.

To make your match

How are you related to the ill person?

Your relative's date of birth - use M/D/YYYY format

Gender identity of your ill relative

Duration of your relative’s primary mental illness.

Primary diagnosis or symptoms of your relative. Please check all that apply as primary conditions.

UndiagnosedAnxietyBipolar DisorderDelusionsDepressionMajor Depressive DisorderManiaObsessive compulsive behaviorPersonality DisorderPsychosisSchizoaffectiveSchizophreniaSuicide IdeationTrauma/PTSD

What other symptoms or conditions does your relative experience?  Do not check the same symptoms as the previous question.

ADHDAggressionAnxietyDelusionsDepressionDissociative DisorderManiaMood DysregulationObsessive compulsive behaviorParanoiaPersonality DisorderSelf-harmSuicide IdeationTrauma/PTSD

Relevant medical, developmental, trauma conditions. Please check all that apply.

Alcohol Use/AbuseSubstance Use/Abuse Addiction - OtherAsperger's SyndromeAutismCognitive DisorderEating DisorderPhysical Abuse/Trauma Sexual Abuse/Trauma Abuse/Trauma - Other Other

Other relevant medical, developmental, behavioral conditions or trauma

Please share any other relevant information or requests here (e.g. if you prefer a Spanish-speaking match)

Please share what is important to you in this connection while understanding that we are not able to match every circumstance. Remember that we promise match by family role and familiarity with general disorders. Also use this space to provide useful clarification, keeping in mind that your upcoming connection is the best place to exchange details. Certainly let us know if you request a Spanish-speaking match.

About you

First name

Last name

Your pronouns

Email address

What is your preferred phone?

MobileHome (2nd phone)

Mobile - start with area code, NOT 1

Home (2nd phone) - start with area code, NOT 1

What is your preferred method for scheduling calls?

How do you find support/relief with the challenges of your relative? (Check all that apply)

Faith	Family
Friends	Hobbies
Nature	Physical Movement
Professional Therapy	Other

Other way you find support

What do you hope to gain in one-to-one match?

Good listening / Not be aloneLearn how to access resourcesShare experience and coping / Gain perspectiveTake care of my health

Please select how you heard about the Family Match program?

Your answers help us keep and raise funding, so this program is FREE. Your answers also guide us in creating programs that serve everyone, in every borough and every identity. Everything you share is confidential.

Your demographics

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 describe your racial identity

Your primary language

Please tell us your primary language

Your gender identity

Your sexual orientation

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