Family-to-Family Class
This form will submit your information electronically when you click on the submit button at the end.
Email address *
Family-to-Family Application
First Name *
Your answer
Last Name *
Your answer
Addresss *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Home phone *
Your answer
Cell
Your answer
Work
Your answer
Please share something about your loved one who is living with a mental health illness. This information provided will help to determine if this program meets your needs. NAMI is here to support you and your family.
Name of loved one with illness *
Your answer
Relationship to you *
Your answer
Age *
Your answer
Gender *
Age of illness onset *
Your answer
Diagnosis if diagnosed *
Your answer
Medications used *
Your answer
Living Arrangements *
Your answer
Other information
Your answer
Thank you for your application. We will get back to you soon.
For questions or additional information about the Family-to-Family course, please contact
Sylvia Gil, Education Coordinator, 323-351-0999 or email sylvia@namilaccc.org
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