NAMI Long Beach Basics Application
Please complete the form below to indicate your interest in taking NAMI Basics. After your application is submitted, you will be contacted when a NAMI Basics class is available.
Basics Spanish? *
First Name *
Your answer
Last Name *
Your answer
Other Adults Attending
List the name(s) of other family member caretakers who are likely to attend with you and how that person is related to the child
Your answer
Address *
Your answer
City, Zip *
Your answer
Phone number: Home, Cell *
Give us the best number to reach you
Your answer
Relationship *
Your child with a mental illness or worrisome behaviors is.......
Required
Age of person with mental health condition: *
Your answer
Type of mental health condition/behavioral difficulties:
This person lives: *
Required
How did you hear about NAMI and our Basics program? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms