NAMI-NYC Family Match Interest Form
Our trained volunteers offer lived experience and emotional support in mental health conditions. Our matches connect by phone over 3 months, twice per month for 30-60 minutes each. Please share some information so we may serve you appropriately in one-to-one support.
Contact information
First name
Last name
What is your preferred phone?
Mobile
Home (2nd phone)
Home (2nd phone)
Mobile
Email address
What is your preferred method for scheduling calls?
Please select...
Phone
Email
About you
How are you related to the person with a mental health condition? I am the:
Please select...
Parent
Spouse/Partner
Adult Child
Sibling
Other Family Member
Your pronouns
Please select...
She/Her
He/Him
They/Them
He/They
She/They
Not Listed
Prefer not to answer
About your ill relative
Your relative's date of birth - use M/D/YYYY format
Gender identity of your ill relative
Please select...
Woman
Man
Transgender Woman
Transgender Man
Non-Binary
Gender Non-Conforming
Other
Prefer not to answer
Primary diagnosis or symptoms of your relative.
Please check all that apply as
primary
conditions.
ADHD
Anxiety
Bipolar Disorder
Borderline Personality Disorder
Delusions
Depression
Dissociative Disorder
Major Depressive Disorder
Mania
Mood Disorder (other than Depression or Bipolar Disorder)
Obsessive Compulsive Disorder
Paranoia
Personality Disorder
Psychosis
Schizoaffective
Schizophrenia
Suicide Ideation
Trauma/PTSD
Undiagnosed
What other challenging symptoms or conditions does your relative 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 or Bipolar 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.
Alcohol Use/Abuse
Substance Use/Abuse
Addiction - Other
Asperger's Syndrome
Autism
Cognitive Disorder
Dementia
Developmental Disorder (other than Autism, Asperger's)
Eating Disorder
Learning Disability
Physical Abuse/Trauma
Psychological Abuse/Trauma
Sexual Abuse/Trauma
Abuse/Trauma - Other
Sleep Issue/Disorder
Other
Other relevant medical, developmental, behavioral conditions or trauma
Duration of your relative’s primary mental illness.
Please select...
Less than 1 year
1-5 years
6-10 years
11-20 years
More than 21 years
Unknown
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 alone
Learn how to access resources
Share experience and coping / Gain perspective
Take care of my health
Please share any other relevant information or requests here (e.g. if you prefer a Spanish-speaking match)
How did you hear about us?
Please select how you heard about the Family Match program?
Please select...
Word of Mouth/Family or Friend
Internet Search
NAMI-NYC Class
NAMI-NYC Helpline
NAMI-NYC Newsletter
NAMI-NYC Support Group
NAMI-NYC Website
NAMI-New York State Newsletter
Other NAMI affiliate
Service Provider
Social Media
1199
Unknown/Undisclosed
Other
Prefer Not to Answer
Request for Demographic Information
This information helps us get funding to keep our programs FREE for everyone.
This information also helps us develop new programs that serve all community members.
Your responses are confidential.
Your street address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
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
Are you Latino/Latina or Hispanic?
Please select...
Yes
No
Prefer not to answer
Your racial identity
Please select...
Alaskan Native/American Indian/Native American
Asian
Black/African American
Hawaiian or Pacific Islander
White
Mixed Race
Prefer not to answer
Other
Please describe your racial identity
Your
primary
language
Please select...
English
Spanish
Other
Please tell us your
primary
language
Your gender identity
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