NAMI Long Beach Family to Family Application
After completing the form below, your contact information will be entered into NAMI Long Beach Family-to-Family Education Program general applicant list. A NAMI Long Beach representative will contact you. You will remain on our applicant list for one year or until you contact us requesting to be removed from the applicant list sooner.

Completing this form does not guarantee registration to the class.
First Name *
Your answer
Last Name *
Your answer
Phone *
Your answer
Other Family Members Attending?
If yes, please use full names AND indicate their relation to your ill relative. If not, please enter "no". Anyone wanting to attend MUST be available to attend all 12 sessions. The family member WITH the illness will not be permitted to attend.
Your answer
Type *
Alternate Phone
Your answer
Email *
Your answer
City *
Your answer
Relationship *
The person WITH the illness is your:
Diagnosis *
The Family-to-Family Program ONLY covers the illnesses listed below. If your relative is undiagnosed, please briefly describe some of their symptoms in the "Other" field.
Is your ill relative an adult? *
If your relative is a minor, the 6-week NAMI Basics Program is more appropriate.
Are you or your ill relative a military veteran? *
Where or how did you find out about Family-to-Family? *
Are you interested in Spanish language class?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy