Referral Form

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Referral Form

Your Name *

Organization *

Email *

Phone Number *

Organization's Address & Zip Code *

Name of Person(s) you are referring: *

Referee's phone number *

Referee's Email Address *

Referee Address & Zip Code *

Reason for Referral (check all that apply) *

Peer 1:1 Support

Family 1:1 Peer Support

Individual Support Group

Family Support Group

Parent Support Group

Suicide Loss Support Group

Teen Support Group

Basics (Online/On-Demand)

Family to Family Mental Health Education 8-week class

WRAP

Peer Workforce Development

Social/Recreation Services

Youth Services

Volunteering/Community Service

Specialty Courts Saturday Support Group

Other:

Required

Referral from Specialty Courts: *

Yes

Acknowledgement of Referral *

By clicking here I confirm the individual(s) is/are aware of this referral.

Required

Release of Information *

By clicking here I understand that to complete this referral, I am required to return a completed Release of Information form (downloadable at the top of this page) to NAMI DuPage, by e-mail or mail. (If there is not an opportunity to have a release of information signed, please indicate the reason in the notes section below).

Required

Additional Information/Notes (Optional)

Do you wish to be contacted for an update on this referral? *

Yes

Thank you! A member of our team will get in touch with the individual you are referring.

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