Appointment Request for 1:1 Family Peer Support Services

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Please note that the process of setting up a 1:1 Family Peer Support appointments takes a minimum of 1-2 weeks and requires paperwork to be completed PRIOR to the meeting with an assigned Peer Support worker. If you feel that you will need assistance with completing the initial paperwork, please let us know.

If your loved one needs urgent mental health care, please visit our Living Room, open Monday-Friday from 3-8 pm. To find out more information about our Living Room, go to www.namidupage.org

For urgent around the clock care, please call the DuPage County Crisis Center at (630) 627-1700 or 988.

Email *

Name *

Phone Number *

Address (Street) *

City *

Zip Code *

Best way to reach you? *

Phone

May we leave you a voicemail or send you an email? *

Yes

Preferred days/times for appointments: *

Preferred appointment type: *

Zoom Videoconferencing

Phone Call

In-Person

No Preference

Relationship to person with diagnosis *

Friend

Parent

Spouse

Other:

What is your loved one's diagnosis(es) and/or symptoms? *

Does your loved one have any substance abuse issues? (alcohol or drugs) that negatively impacts their daily life? (i.e., concerns with relationships, employment, or health) *

Yes

Has your loved one ever been involved in the DuPage County court system? (this is confidential and for grant purposes only)
*

Yes

If yes, was the involvement in MICAP, Drug Court, or Veteran's Court?

Yes

Clear selection

How did you hear about the NAMI DuPage 1:1 Peer Support Services? *

Website

Social Media

Friend/Family

NAMI Community Booth/Event

NAMI DuPage Staff

Professional Service or Organization

Court or Legal System

Therapist or Psychiatrist

Other

Please tell us the top issue or issues you would like to discuss with a Family Support Peer worker

Please note that an initial Peer Support services session is $30/hour, and $15/hour for additional meetings. If you would like to request a sliding fee consideration for these sessions, please indicate below. (No fees are due until the time of appointment) *

I will need financial consideration and will complete the sliding fee scale application in my initial client intake paperwork

I do NOT need an application for financial consideration

I understand that the NAMI DuPage 1:1 Peer Support services are not intended for immediate crisis care. If this is a crisis I will reach out to my care team or call 988 in the event of an emergency. *

Yes, I understand. If me or my loved one is in crisis, I will seek crisis services support.

That's it! Click submit, and the NAMI DuPage Resource and Support department will be in contact in 1-2 weeks. Be sure to check your email for an email from Theranest to complete the initial paperwork.

Send me a copy of my responses.

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