NAMI Membership Form
Please enter your full name. If purchasing a Household membership, list all members separated by a comma.
How did you hear about us?
Word of Mouth
Healthcare Provider Referral
NAMI Program (please list)
Did a current NAMI member refer you to get a membership?
Please add their name so that we can thank them!
Let us know about you
Please check ALL that apply
person living with a mental illness
family member/friend (of an adult)
family member/friend (of a child/adolescent
mental health or other provider
veteran or family member of a veteran
Age of Primary Member
Never submit passwords through Google Forms.
This form was created inside of NAMI VT.
Terms of Service