Service Assessment Request

Service Assessment Request

Please note: there is no charge for support or advocacy services!
Welcome to NAMI McHenry County!

We are so happy that you are taking this step.. We appreciate how difficult it can be to start.. We can help with that!

Agency Office Hours: Monday through Friday from 8:30am until 4:30pm

If you have questions or need help with this form, please email help@namimch.org or call and leave a message for the Service Team 815.526.8243

Filling out this form will help you access the following services:
- Recovery Support Program: For Individuals 18+ needing support partners with a mental health condition. We will meet with you 1:1 to learn more about your needs and help you access long-term supports in the community. We are folks in recovery too! We are here to help you navigate and maintain quality of life on your journey!
  - Also included: Weekly Connections Support Groups where we tackle the challenges of everyday life and the challenges that come with a mental health disorder. (Ages 18+)
- Family Support Program: For Friends & Families of people living with a mental health condition, including parents who need support for their children. We are Family members supporting loved ones in recovery too! We can partner with you to help advocate for your loved one by collaborating with the community for safety while we support you on your journey of understanding the system as well as the adjustments needed to maintain your own wellness and the health of the whole family.
  - Also included: Weekly Family Support Groups where we problem solve the struggles and celebrate even the smallest win’s along the way! (Ages 18+)
Need Support Now? Use the following resources:

*If you need assistance with immediate resources, please dial 211
*For a mental health crisis, please dial 988
*For a safety-related crisis, please dial 911 and ask for a CIT trained officer

You are not alone! Come for the help & support, stay for the comradery and life-long friendships.
Service Assessment Request
Are you seeking support for yourself as an individual with a mental health condition or as a family member of someone with a mental health condition?*

I have a mental health condition and am seeking support for myselfI have a friend or family member with a mental health condition, and am looking for ways I can help them (or ways that I can find support myself)
Name (Chosen)*

First NameLast Name
Date of birth*

MonthDayYear
Date
Gender Identity*
Pronouns
Race and Ethnicity (check all that apply)*

WhiteHispanic or Latino/a/eBlack or African AmericanAsianAmerican Indian or Alaska NativeMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderSome other race / ethnicityI don't knowPrefer not to answer
Do you have a permanent residence?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Email address. We WILL send you communication and resources via email. Please ensure that you are providing an email address that you do have access to and that you check regularly, including your spam folder. If you don't have an email, please use help@namimch.org*
example@example.com
Confirm email address*
example@example.com
Phone Number*
Please enter a valid phone number. If you don't have a phone number, please enter (555) 555-5555
NAMI has my permission to leave voicemails at this phone numberNAMI has my permission to send text messages to this phone number
Preferred contact method*
Description of Need. Please tell us about what kind of services you’re looking for and what might be most helpful for yourself and/or your loved one.*
I am interested in the following service(s):*

1:1 Recovery Support / Family Support (individual meeting(s) with a recovery support specialist to assist with service navigation and advocacy)Connections Support Group (ages 18+)Family Support Group (ages 18+)
Over the last two weeks how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge.
Not being able to stop worrying or controlling your thoughts.
Lack of interest in doing things.
Feeling sad or depressed.
Referred by:
Were you referred to NAMI MCH by anyone else? If so please share that with us here.
Would you like to join our distribution list to stay up to date on the latest NAMI MCH services, events, and offerings?*

YesNo
Consumer Rights

This reflects what NAMI MCH regards as our clients' rights:
Respect

Confidentiality

Access to your record

No discrimination or predjudice in receiving services

Ability to agree to or refuse any service in your service plan

Ability to make decisions about taking medication

Privacy from secret observation

Knowledge of any reasons for termination or denial of service

File a complaint or grievance (with help if requested)
Grievance Policy

If at any time your family is not satisfied with the services offered by NAMI, you should make your complaint known to your Recovery Support Specialist. If the problem is not resolved to the family’s satisfaction, you may contact Abbey Nicholas, Executive Director, at 815-357-7100. If the Executive Director is unable to resolve the problem to your satisfaction, please call Heidi Jenkins, NAMI Board Co-President, at 815-893-9798 and she will assist you in resolving the problem by consulting with all parties and coordinating a meeting if necessary. If all of the above measures fail to result in problem resolution to your satisfaction, you have the option of contacting the following agencies for assistance: McHenry County Mental Health Board (620 Dakota Avenue, Crystal Lake, IL 60012); Illinois Department of Mental Health & Developmental Disabilities (160 North LaSalle Street, Suite 1000, Chicago, IL 60601, 312-814-4228); Equip for Equality (11 E. Adams Street, Suite 1200, Chicago, IL 60603, 1-800-537-2632)
I hereby authorize NAMI McHenry County to store the information provided above in a Data Management System which is shared with the McHenry County Mental Health Board (MHB). I understand MHB is a funding source for the program and allows services to be offered at no cost to the community. This authorization becomes effective on the Electronic Signed Date below and will expire after 1 (one) year. I also acknowledge that I am giving consent for NAMI McHenry County staff to contact me via the contact information provided above and I will be responsible for checking each of those contact methods for follow-up communications.*

I agree
Signature*
DateTime
Should be Empty:

Service Assessment Request

Service Assessment Request

Consumer Rights

Grievance Policy