First Name *

Last Name *

Email address *

Phone number *

I am registering for the following class. *

I understand that, according to NAMI policy and for confidentiality reasons, I must be in a secure place with no one else around and must always remain visible on camera while this class is in session. *

Why are you interested in taking the Peer-to-Peer course? *

Do you agree to keep confidential the disclosures of other participants in the class? *

Do you agree to speak to others only of your own experiences? *

Eight sessions over 4 weeks is a substantial time commitment for a course. You are expected to attend each and every session. Do you foresee any attendance problems? If yes, please explain. *

The course material in Peer to Peer can be intensive, and it may be helpful to talk to a professional about some of your experiences in the class. Do you have a support system or person you can turn to? *

I will adhere to the following Peer to Peer guidelines: (Applicants must be willing to check all boxes to be considered for this class). *

I understand that this is an education class and NOT a support group. *

I understand that I will be asked to share my story of mental illness as one of the components of this class. *

I understand that, according to NAMI policy, one of the facilitators will contact me by phone prior to the start date for a pre-interview before my registration in the class can be finalized. *

I confirm that I am over 18 years of age and identify as having a mental illness. *

Is there any additional information that you need to let our facilitators know? If not, put "none." *

Please provide us with the first and last name and phone number of an emergency contact person. *

For the purpose of distributing books/materials for this class, please provide us with your mailing address, city, state, and zip. *

Are you a veteran? *