NAMI UT Program Registration Form

Are you 18 years or older?

YesNo
We apologize but you must be 18 years or older to register for support groups or classes with NAMI Utah at this time.

NAMI Utah programs are always provided free of charge. To assist us in securing continued funding for these services, please answer the following confidential questions:

The information on this page is only used for statistical analysis.
How did you hear about NAMI Utah?
Are you currently receiving Medicaid benefits?*

YesNo
How many people live in your household?*
What is your household's total annual income? *

Contact Information

Please use the primary Home Address from where you will attend the program.
Name*

First NameLast Name
Pronouns
Ex: she/her, he/him, they/them
Nickname
Email*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which Utah county do you live in?*
Choose 'Out of State' if not in Utah.
Emergency Contact Name and Phone*
We need someone to contact in case you experience an emergency while attending a NAMI Utah programs event
Your contact information is strictly confidential. We will never share your information with anyone. The only exception would be an emergency in which we think you are in imminent danger.

Choose a language to continue:*

EnglishEspañol
Un representante de NAMI Utah se pondrá en contacto con usted para informarle sobre nuestros programas en español.

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

I Support a loved one - Family programsI have one myself - Peer Programs

Online Family Support Groups

These are drop-in groups offered via Zoom on Tuesday and Thursday nights at 7:00-8:30 p.m. MST. Once you are registered, you are free to attend either (or both) groups.
Family Support Group Online

Yes
In-Person Family Support Group

LOCATION: Utah State Hospital in Provo, UT on Wednesday nights @ 7:00-8:30 p.m MST
In Person Family Support Group at Utah State Hospital

Yes
Online Family Support Classes

These are classes are offered via Zoom every couple of months. A NAMI Utah representative will contact you regarding the details of the next class. Family-to-Family is offered for anyone supporting a loved one of any age / relationship who has a mental health condition. Basics is a class that is focused on parents or caregivers who have a school aged child 19 or younger with a mental health condition.
Family-to-Family - 8 week class

Yes
Basics - 6 Week Class

Yes

Online Connection Support Group and Peer-to-Peer Class

These are offered via Zoom. Currently the Connection Support Group is offered on Mondays @7pm, Wednesdays at both 12:30pm and 7pm., Fridays @ 7pm, and Saturdays at 10:30am Peer-to-Peer is offered every couple of months and a NAMI Utah representative will contact you regarding the details of the next class. These are "Peer Led" programs, meaning the leaders themselves have a mental health condition and are volunteering. These are not intended to replace traditional therapy, nor be construed as professional advice.
Connection Support Group Online

Yes
Peer-to-Peer Class Online

Yes
In-Person Connection Support Group

These are hosted at the NAMI Utah main office located at 3269 S Main St #230 Salt Lake City, UT 84115 every Monday night at 7:00-8:30 p.m.
In-Person Connection Support Group

Yes

Entiendo que los programas de NAMI son confidenciales. Esta confidencialidad solo se romperá si algún miembro de NAMI considera que corro peligro de hacerme daño a mí mismo o a otra persona. En ese caso, se pondrán en contacto con mi contacto de emergencia y/o con la línea de atención de crisis. Comprendo que esto es para protegerme y garantizar mi seguridad.*
Initial
Doy permiso a NAMI Utah para que me envíe correos electrónicos. Puedo cancelar mi suscripción en cualquier momento.*
Initial
I understand that NAMI programs are confidential. That confidentiality will only be broken if NAMI member think I are in danger of hurting myself or someone else. They will contact my emergency contact and/or the crisis line. 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 any time.*
Initial
Should be Empty:

We apologize but you must be 18 years or older to register for support groups or classes with NAMI Utah at this time.