Peer-to- Peer Class Registration Form

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Today's Date *

YYYY

Information regarding who can register for this class

The person who plans to be in attendance for this Peer-to-Peer (P2P) class must be the person who completes the registration for this class. Those in attendance should be here because they want to be and not because someone else wants them to be in the class.

The other requirements to attend this P2P class are:

A. You must be 18 years of age or older

B. You must be able to read

C. You must be OK with participating in group discussions

D. You must understand that this class is focused on mental health recovery and wellness.

E. You must be in some stage of mental health recovery or are open to developing your own mental health recovery

F. You must be OK with self disclosing that you have a mental health condition just as everyone else in the class

G. You must be available to attend this 10 week class for 8 of the 10 classes. The class begins on Friday, February 3, 2017 and ends on Friday, April 7, 2017 and is held 11:00 am - 1:00 pm each class. If you know that you can't commit to this at this time please do not register.

Thank you for your understanding in this matter.

Provide your age *

e.g. your age

Select your gender *

e.g. are you male, female, trans

Female

Male

Trans

Prefer not to disclose

Other:

Select your Ethnicity/Race *

e.g. are you Hispanic, Asian

Hispanic/Latino

African America/Black

Caucasian/White

Native American

Asian American/Asian

Other:

Select your diagnosis (select all that apply) *

e.g. you have a diagnosis of depression and anxiety

Schizophrenia

Depression

Bipolar

Schizoaffective

OCD

PTSD

Panic/Anxiety Disorder

Unsure

Other:

Required

Your first and last name *

e.g. your name

Your phone number *

e.g. (123) 456-7890

Your Address *

e.g. 1234 Street Ln.

Your email address

e.g. imasample@domain.com

How did you learn about this NAMI Dallas P2P class? *

NAMI Dallas website

NAMI Dallas Helpline Call

NAMI

Family member or friends

Search engine such as Google, BING, Yahoo

Advertisement online or print

Mental health professional such as a psychiatrist, counselor, therapist

Other:

Details on our registration follow-up phone call to you

Thank you for registering for our NAMI Dallas Peer-to-Peer (P2P) class. Please be advised that one of our P2P mentors who will be teaching your class will contact you using the contact information you provided prior to the class start date to speak with you in regards to your registration for this P2P class.

The purpose of their call is to:

A. Confirm that you are still planning on attending the P2P class

B. To provide you with any details about the P2P class you may need in order to get there

C. To be sure that the P2P class fits your needs.

In the meantime please be sure to view our peer support group meeting schedule located at http://www.namidallas.org/peer-support.html and go and check out a peer support group meeting closest to you as your schedule allows in order to gain support from others who have been where you are and can share their experience, strength, and hope with you. Thank you for patience in this registration process and we hope to see you soon. Take care.

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