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.
Format: (000) 000-0000.
Emergency Contact Name:
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First Name
Last Name
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
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.
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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 Thursday in person at 6:00 PM - UPMC Memorial Hospital
Family Support Group - 1st Wednesday each month 7:00 pm - via Zoom
Family Support Group - Every other Tuesday in person (150 Farm Lane Suite 100)
Other
Would you like to receive text/SMS message alerts for the groups which you selected interest in? (Message and data rates may apply)
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Yes
No
Please contact carter.stokes@namiyorkadams or (717) 848-3784 Ext. 105 for any questions or concerns.
Please verify that you are human
*
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