NAMI UT Program Registration Form

Program Registration Form

Welcome! We at NAMI Utah are delighted that you are interested in our online programs. For your safety we require you to complete this registration form. It will only take a few minutes.
Would you like to register for a program in English or Spanish?*

EnglishSpanish (Register here: http://latinobehavioral.org/services/education/)

Are you supporting someone with a mental health condition or do you have a mental health condition yourself?*

Supporting a loved one (Family programs)I have one myself (Peer Programs)
¿Está apoyando a alguien con una condición de salud mental o usted mismo tiene una condición de salud mental?*

Apoyando a un ser querido (Programas familiares)Yo mismo tengo uno (Programas de pares)

All information you provide will be kept confidential. We do not share your information with anybody unless there is an emergency.
**Our support groups and classes start on time. Please arrive at least 5 minutes early to avoid missing a group.**
Family Programs*

Online Basics Course: A 6-week course for parents of children 18 and younger with mental health conditions.Online Family-to-Family Course: An 8-week course for family members and loved ones of those with mental health conditions.Online Family Support Group: For family members and loved ones of those with mental health conditions. (MONDAYS, 7:00-8:30 pm MST)Online Family Support Group: For family members and loved ones of those with mental health conditions. (Tuesdays, 7:00-8:30 pm MST)Online Family Support Group: For family members and loved ones of those with mental health conditions. (Thursdays, 7:00-8:30 pm MST)In-Person Family Support Group (Provo, Utah): For family members and loved ones of those with mental health conditions. (First and Third Wednesdays, 7:00-8:30 pm MST) Utah State Hospital, Henninger Administration Building 1300 E Center Street Provo, UtahStarting October 5: In-Person Family Support Group (Cedar City, Utah): For family members and loved ones of those with mental health conditions. (First and Third Thursdays, 7:00-8:30 pm) Southwest Behavioral Health Center 245 E 680 S Cedar City, Utah
Programas familiares*

Grupo de apoyo familiar: Grupo de apoyo familiar español (primer y tercer martes del mes, 7:00-8:30 pm MST)Bases y Fundamenots: Un curso de 6 semanas para padres de niños menores de 18 años con condiciones de salud mental.Familia a familia: un curso de 8 semanas para familiares y seres queridos de personas con problemas de salud mental.
Programas de pares*

Persona-a-Persona: un curso de 8 semanas para personas con problemas de salud mental
Peer Programs*

Peer-to-Peer: An 8-week course for individuals with mental health conditionsProgression: A 6-week course for teens 13-18 living with mental health conditions.Connection Support Group: For adults living with mental health conditions. (MONDAYS, 7:00-8:30 pm MST)Connection Support Group: For adults living with mental health conditions. (WEDNESDAYS, 12:30-2:00 pm MST)Connection Support Group: For adults living with mental health conditions. (WEDNESDAYS, 7:00-8:30 pm MST)Connection Support Group: For adults living with mental health conditions. (FRIDAYS, 7:00-8:30 pm MST)Connection Support Group: For adults living with mental health conditions. (SATURDAYS, 10:30 am-12:00 pm MST)
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
How did you hear about NAMI Utah's online programs?*
Email*
example@example.com
Phone Number*
Where will you be attending the program from? (Please no PO Boxes) This is required for your safety.*

Street Address

CityState

Zip Code
County*
County*
Are you 18 or older?*

YesNo
If you experience an emergency during a program would you like us to contact someone?*

YesNo
If yes, who should we contact? (name AND phone number)
Is there anyone else in your household you would like to register with you?*

YesNo
What is their Name?*

First NameLast Name
What is their Email?*
example@example.com
What is their Phone Number?*

Area CodePhone Number
Are they 18 years or older?*

YesNo
What is Progression?

NAMI Utah’s Progression course is for teens with mental health conditions. The six week course is taught by two Progression co-teachers who are young adults with mental health conditions and in recovery. Our teachers serve as role models and peers allowing teens to see first-hand that there is hope. Teachers only become certified after passing a rigorous training process and criminal background check. Teens meet other teens with mental health conditions in a safe, comfortable environment. They learn about what mental illness is, causes, symptoms, harmful impacts of mental illness, triggers, stigma, treatments, self-care, recovery, advocacy and more.
Signature: Triggers: Some mental health topics could cause an emotional reaction from your teen, called a trigger. This is normal, and your teen may or may not experience a triggering reaction to the content of the classes. There is time set aside during each class to talk about triggers. You need to be aware that triggers may occur so you can talk to your teen, if they should experience one. I understand that NAMI Utah requires a trusted adult 18+ to be in the home when the participant is taking the course online.*

Clear
Signature: Confidentiality Disclosure: I understand that though most of what happens throughout the Progression course is confidential there are exceptions including: if a participant shares they are thinking of harming themselves or someone else; if a participant shares that they have previously inflicted serious bodily harm on someone; or if a participant shares that they are being physically, sexually or emotionally harmed. In these situations parents/guardians and mental health professionals will be contacted for the safety of the participant. Teachers review the confidentially protocol with participants during the first class.*

Clear
Signature: Permission to Attend Progression: Because teens are minors, parents or guardians are required to give permission before they can attend the course. By signing below, I give permission for my teen to participate in Progression. I also understand that teachers will contact my teenager primarily through texting or email. If I have questions or concerns at any time throughout the course I may contact the NAMI Utah Programs Director, and author of Progression, Robin Holcomb at 801.869.2884 or robin@namiut.org.*

Clear
Parent/Guardian*

First NameLast Name
Parent/Guardian*

Area CodePhone Number
Parent/Guardian Email*
example@example.com
Progression Participant*

First NameLast Name
Participant Birth Date*

MonthDayYear
Date
Participant Age*
Participant*

Area CodePhone Number
Participant Email*
example@example.com
Emergency Contact 1: Should there be an emergency of any sort during the Progression course, we need to know who to contact. Please complete this form and be sure your teachers have it on or before the first day of class.*
Name/Relationship/Phone Number
Emergency Contact 2: Should there be an emergency of any sort during the Progression course, we need to know who to contact. Please complete this form and be sure your teachers have it on or before the first day of class.*
Name/Relationship/Phone Number
Emergency Contact 3: Should there be an emergency of any sort during the Progression course, we need to know who to contact. Please complete this form and be sure your teachers have it on or before the first day of class.*
Name/Relationship/Phone Number
I understand that NAMI programs are confidential unless teachers believe I am in danger of hurting myself or someone else. If a teacher is worried about my safety they will contact the crisis unit and my emergency contact. I realize this is to protect me and keep me safe:*
(Initial)
I give NAMI Utah permission to send me emails (I can opt out at a later time):*
(Initial)
Should be Empty:

Program Registration Form

All information you provide will be kept confidential. We do not share your information with anybody unless there is an emergency.

What is Progression?