Online NAMI Family Support Group Registration Form

Online NAMI Family Support Group Registration Form
NAMI Southern Nevada’s Family Support Group is a free, confidential support group for any adult with a loved one who has experienced symptoms of a mental health condition.
- Gain insight from the challenges and successes of others facing similar experiences.
- Meetings are led by trained facilitators who have a loved one that has experienced symptoms of a mental health condition.
NAMI Family Support Group will be held VIRTUALLY on the 2nd and 4th Tuesday of each month.

Safety: Emergency contact information must be filled in order to receive your invite to group.

Confidentiality: Support group participants discuss personal and sensitive information that requires that privacy and confidentiality be upheld by all participants and facilitators. The only exceptions to confidentiality are times when an individual is at risk of immediate danger to him or herself or others.

By submitting this form, you are agreeing to respect the confidentiality of all participants. If you have any questions or concerns, please email supportgroups@namisouthernnevada.org. We look forward to having you join group!
Zoom Link and Registration Information

Registration is not automatic. We manually process all registrations.

Registration forms must be submitted at least 48 hours prior to attend an upcoming scheduled meeting group to attend that week's support group. If you register after this time, your registration will be processed for the following meeting.

If there are any errors in your registration (e.g., incorrect address or missing emergency contact), we will contact you and your Zoom link will be delayed until the issue is resolved.

If you have concerns about your application or questions about filling out the information below, please contact Programs Manager, Sariah Nokes via text at 725-238-1402 or email us at supportgroups@namisouthernnevada.org
This group is for any adult with a loved one who has experienced mental health challenges. Are you a relative, loved one, or caregiver of an individual who is 18 years old or older who experiencing mental health challenges?*

Yes, I am.No, I am not.I have a relative or loved one under the age 18 years old who experiences mental health challenges
Full Name*

First NameLast Name
Nickname
If you prefer a nickname to be used during the group, please indicate it here.
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Phone Number*
Are you 18 years old or older?*

YesNo
I recognize that Family Support Groups will be held every 2nd and 4th Tuesday, from 6:00pm - 7:30pm.*

Yes, I recognize that.
Safety and Contact Information

Your contact information will remain private and confidential to your respective FSG Facilitators, the Program Coordinator, and your Emergency Contact. We will contact the Emergency Contact to make sure they are aware and agree to being listed. We will also confirm with them that they have record of the residential address, phone number, and email address you have placed on file.
Residential Address (Must include Street Number, Street Name, Unit Number, City, State, and Zip Code). NOTE: WE CANNOT REGISTER INDIVIDUALS WITHOUT ALL PARTS OF YOUR RESIDENTIAL ADDRESS.*

Street Address

Street Address Line 2 (including Unit or Apartment # if applicable)

CityState / Province

Postal / Zip Code
Emergency Contact Person Name*

First NameLast Name
Emergency Contact Phone Number (MUST be a different number than the one you have provided for yourself)*
Emergency Contact Phone Number (MUST be a different number than the one you have provided for yourself)*
Please enter a valid phone number.
Emergency Contact Email Address*
example@example.com
Are you a veteran?*

YesNo
Are you a new NAMI Support Group Participant?*

YesNo
Email
I would like the following engagement related to emails being sent to me:*

Receive only emails about NAMI Support Groups (Reminders with Zoom Access, Cancelations, Changes, Materials, etc.)Receive Support Group Reminders and Updates along with occasional NAMI Upcoming Events and Opportunities
I recognize that, in the future, if I no longer want emails or text messages, I wound have to contact NAMI at namisupportgroups@namisouthernnevada.org so that NAMI can remove my information.*

Yes, I recognize that.
Should be Empty:

Online NAMI Family Support Group Registration Form

Safety and Contact Information

Email