SUPPORT GROUP REGISTRATION
Email
*
example@example.com
Name
*
First Name
Last Name
Preferred Pronouns:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Have you ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?
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Yes
No
Prefer Not to Answer
I understand that NAMI Online Support Groups are not intended to replace or be used as a substitute for clinical and/or medical services, and facilitators are NAMI-trained peers, not mental health professionals.
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I Understand
I understand that by participating in NAMI York-Adams Online Support Groups, I agree to abide by Group Guidelines & Principles of Support, and can be removed and/or banned from any meeting at the discretion of the facilitator.
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I Understand
All information provided stays with us, we will not forward or sell your information. NAMI York-Adams Counties PA will add you to our mailing list and will send you information pertaining to NAMI York-Adams Counties PA functions, events and programming schedule in our monthly newsletter.
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I Understand
Are you interested in becoming a member of NAMI York-Adams Counties PA?
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Yes
No
Maybe
Which group(s) are you interested in attending?
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Connections Support Group - Wednesday 6:00 pm via Zoom
Connections Support Group - 2nd and 3rd Wednesday in person - UPMC Memorial Hospital
Family Support Group - 1st Wednesday each month 7:00 pm - via Zoom
Family Support Group - 2nd Tuesday each month 11:30 am - via Zoom
Other
Please contact info@namiyorkadams.org or (717) 848-3784 Ext. 103 for any questions or concerns.
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