SOSA Interest Form

Survivors of Suicide Attempt (SOSA) Support Group

Please fill out the following form to sign up for the next SOSA Support Group through the McHenry County Suicide Prevention Task Force
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 clarissa@namimch.org or call and leave a message for the Education Team 815.526.8243

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.

We currently have a SOSA Group in progress. Please complete this JotForm to be kept informed on the next available group.
Survivors of Suicide Attempt (SOSA) Support Group Registration
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
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 numberNAMI does not have my permission to leave a voicemail at this phone numberNAMI does not have my permission to send text messages to this phone number
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*
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Survivors of Suicide Attempt (SOSA) Support Group

Survivors of Suicide Attempt (SOSA) Support Group Registration

Consumer Rights

Grievance Policy