Appointment Request for 1:1 Individual Peer Support Services

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Please note that the process of setting up a 1:1 Peer Support appointment 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 you need more urgent 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.

Please note: if requesting services for Individual Peer Support, the Individual should be the one completing this request form.

Email *

Name *

Phone Number *

Address (Street, City, Zip) *

Date of Birth *

YYYY

Best way to reach you? *

Phone

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

Yes

Which type of appointment are you requesting? *

Please note: if requesting services for Individual Peer Support, the Individual should be the one completing this request form. For exceptions or questions, please contact the Support team at NAMI DuPage.

If you are seeking services to support a loved with living with a mental health condition, please indicate "Family Support" below.

Individual Peer Support (services for the individual living with a mental health condition)

Preferred days/times for appointments: *

Preferred appointment type: *

Zoom Videoconferencing

Phone Call

In-Person

No Preference

What is your diagnosis(es), and/or symptoms? *

Is the use of alcohol or substance use having a negative impact on your daily life? (i.e., concerns with relationships, employment, or health) *

Yes

Are you now, or have you ever been involved in the DuPage County Court System, not counting traffic offenses? (this is confidential and for grant purposes only)
*

Yes

If yes, were you involved 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 list the top three areas in your life that you would like to work on (for individual peer support requests):

Please let us know anything else that you think would be helpful in matching you for Peer Support (please note: we will make every effort to match you with your requests, but we cannot guarantee that we will be able to do so)

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, visit the Living Room, Call 988, or will use my crisis plan. *

Yes, I understand. If I am 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. Please note that there may be a delay in matching clients with Peer support due to staffing shortages.

Send me a copy of my responses.

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