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Name
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First
Last
Preferred Name
Are you a Veteran?
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Are you a college student?
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Yes
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Are you 18 years or older?
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Address
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Diagnosis of mental health condition?
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Do you currently work with a counselor, doctor or mental health provider?
Yes
No
Why are you interested in taking the Peer-to-Peer course?
*
Eight weeks is a substantial time commitment for a course. We do expect you to be able to attend each week. Will you commit to attending all 8 weeks of class from 5pm – 7pm?
*
Yes
No
Will you agree to keep confidential the disclosures of other participants?
*
Yes
No
Will you agree to speak to others only of your own experiences?
*
Yes
No
Did anyone refer you to take this course? If so, who? OR How did you hear about this course?
*
Have you taken any other NAMI courses? If so, which?
*
Do you attend the NAMI Mental Health Wellness Center?
*
Yes
No
Do you have any chemical sensitivities, special needs, or allergies we need to be aware of?
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Do you have any immediate questions for us?
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