NAMI UT Program Registration Form

Program Registration Form

Welcome! We are delighted that you are interested in our 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

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 anyone 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.**
Online Family Programs*

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: 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, Utah.Online Basics Course: A 6-week course for parents of children 18 and younger with mental health conditions. (Coming soon!)Online Family-to-Family Course: An 8-week course for family members and loved ones of those with mental health conditions. (Coming soon!)In-Person Family-to-Family Course: An 8-week course for family members and loved ones of those with mental health conditions. Utah State Hospital, Henninger Administration Building 1300 E Center Street Provo, Utah. (Coming Soon!)
Classes (hidden here so they can be added to active jotform once they are active again:
- 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.
Programas familiares*

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*

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)In-Person Connection Support Group: For adults living with mental health conditions. (First and Third Mondays, 7:00-8:30 pm MST) NAMI Utah State Office 3269 S Main St. Suite 230 Salt Lake City, UT 84115.Peer-to-Peer: An 8-week course for individuals with mental health conditions. (Coming soon!)
Class hidden because it's inactive, but put here so it can be easily added when it is active again:
- Peer-to-Peer: An 8-week course for individuals with mental health conditions
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?*
Are they 18 years or older?*

YesNo
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*
Parent/Guardian Email*
example@example.com
Progression Participant*

First NameLast Name
Participant Birth Date*

MonthDayYear
Date
Participant Age*
Participant*
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 anyone unless there is an emergency.