NAMI UT Course Registration Form

Course Registration Form

Welcome! We at NAMI Utah are delighted that you are interested in our online courses. For your safety we require you to complete this registration form. It will only take a few minutes. Once you have completed the registration form you will be contacted within a week of when the next course begins.
Today's Date *

Month Day Year
Date
Name *

First Name Last Name
How did you hear about NAMI Utah's online courses? *
Below are courses starting soon, please choose the one you would like to attend. *

Peer-to-Peer Course: An 8-week course for individuals with mental health conditions. Family-to-Family Course: An 8-week course for family members and loved ones of those with mental health conditions. Basics Course: A 6-week course for parents of children 18 and younger with mental health conditions. Progression: A 6-week course for teens 13-18 living with mental health conditions. Persona-a-Persona Curso: Un curso de 8 semanas para personas con problemas de salud mental. (Peer-to-Peer en Español). Familia-a-Familia Curso: Un curso de 8 semanas para familiares y seres queridos de personas con problemas de salud mental. (Family-to-Family en Español). Bases y Fundamentos Curso: Un curso de 6 semanas para padres de niños menores de 18 años con problemas de salud mental. (Basics Enespañol).
Age Group *

18-30 30-40 40-50 50-60 Over 60
Email *
example@example.com
Phone Number *

Area Code Phone Number
Home Address *

Street Address

City State

Zip Code
County *
County *
If you experience an emergency during a class would you like us to contact someone? *

Yes No
If yes, who should we contact? (name AND phone number)
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 Name Last Name
Parent/Guardian *

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

First Name Last Name
Participant Birth Date *

Month Day Year
Date
Participant Age *
Participant *

Area Code Phone 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:

Course Registration Form

What is Progression?