Signature Program Leader Interest Form

Name*

Prefix First Last

Address*

Street Address Address Line 2 City State ZIP Code

County*

Home Phone*

Cell Phone

Email*

Emergency Contact Name*

Prefix First Last

Emergency Contact Relationship*

Emergency Contact Phone*

Sponsoring NAMI Affiliate (based on class location)*

NAMI Four Rivers (MS) (Amite, Adams, Claiborne, Franklin, Jefferson, Lincoln, Lawrence, Pike, Wilkinson and Walthall counties)
NAMI Central Mississippi (Copiah, Hinds, Lincoln, Madison, Rankin and Simpson counties)
NAMI Gulf Coast (Hancock, Harrison, Pearl River, Stone, George and Jackson counties)
NAMI Meridian (Clarke, Jasper, Kemper, Lauderdale, Leake, Neshoba, Newton, Scott and Smith counties)
NAMI Oxford (Calhoun, Lafayette, Marshall, Panola, Tate, Yalobusha, Benton, Chickasaw, Itawamba, Lee, Monroe, Pontotoc and Union counties)
NAMI Pine Belt (Covington, Forrest, Greene, Jeff Davis, Jones, Lamar, Marion, Perry and Wayne counties)
NAMI Vicksburg (Warren and Yazoo counties)
County Not Listed/Virtual Affiliate

Are you a member of the NAMI affiliate you selected?*

Yes
No

If not, what affiliate are you a member of?*

NAMI Four Rivers (MS) (Amite, Adams, Claiborne, Franklin, Jefferson, Lincoln, Lawrence, Pike, Wilkinson and Walthall counties)
NAMI Central Mississippi (Copiah, Hinds, Lincoln, Madison, Rankin and Simpson counties)
NAMI Gulf Coast (Hancock, Harrison, Pearl River, Stone, George and Jackson counties)
NAMI Meridian (Clarke, Jasper, Kemper, Lauderdale, Leake, Neshoba, Newton, Scott and Smith counties)
NAMI Oxford (Calhoun, Lafayette, Marshall, Panola, Tate, Yalobusha, Benton, Chickasaw, Itawamba, Lee, Monroe, Pontotoc and Union counties)
NAMI Pine Belt (Covington, Forrest, Greene, Jeff Davis, Jones, Lamar, Marion, Perry and Wayne counties)
NAMI Vicksburg (Warren and Yazoo counties)
County Not Listed/Virtual Affiliate
Not a NAMI member

(Optional) If available, please provide your membership expiration date.

Are you a peer or family member?*

Peer (an individual with a mental health condition)
Family Member (relative, caregiver or loved one of a person with a mental health condition)

What program(s) would you like to lead or facilitate?*

NAMI Peer-to-Peer: NAMI Peer-to-Peer is a recovery-focused educational program for adults who wish to establish and maintain wellness in response to mental health challenges. The course provides critical information and strategies related to living with mental illness.
NAMI Connection Recovery Support: NAMI Connection is a weekly recovery support group for people living with mental illness in which people learn from each others’ experiences, share coping strategies, and offer each other encouragement and understanding.
NAMI In Our Own Voice: In Our Own Voice (IOOV) is a unique public education program developed by NAMI, in which two trained peer speakers share compelling personal stories about living with mental illness and achieving recovery.

Is the person with the mental health condition an adult (18 and up) or a minor?*

Adult
Minor

What program(s) would you like to lead or facilitate?*

NAMI Family-to-Family: The Family-to-Family Education Program is a free, 12-class course for family caregivers of adult individuals with severe mental illnesses.
NAMI Family & Friends: NAMI Family & Friends is a free 90-minute or four-hour seminar that informs people who have loved ones with a mental health condition how to best support them.
NAMI Family Support Group: NAMI Family Support Group is a peer-led support group for family members, caregivers and loved ones of individuals living with mental illness.

What program(s) would you like to lead or facilitate?*

NAMI Basics: NAMI Basics is a signature education program for parents and other caregivers of children and adolescents living with mental illnesses.
NAMI Family & Friends: NAMI Family & Friends is a free 90-minute or four-hour seminar that informs people who have loved ones with a mental health condition how to best support them.
NAMI Family Support Group: NAMI Family Support Group is a peer-led support group for family members, caregivers and loved ones of individuals living with mental illness.

Have you ever taken a NAMI educational course before?*

Yes
No

Which course(s) have you taken before?*

NAMI Peer-to-Peer
NAMI Family-to-Family
NAMI Basics
NAMI Family & Friends

PLEASE NOTE: Once a training course is available and you express interest in being trained, you may be asked additional questions as part of the screening process. By checking the box below, you confirm that you understand this statement.*

I understand.

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