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Family-to-Family Class Registration...

Complete the following registration form to attend an upcoming Family-to-Family class.
All information is confidential and will be used to ensure that class content is appropriate for your needs.

Title: Select... Mr. Mrs. Ms. Dr. Admiral Ambassador Brother Captain Cardinal Chief Colonel Commander Commissioner Corporal Councilmember Deacon Dean Delegate Father General Governor Honorable Judge Lieutenant Major Officer Pastor President Rabbi Representative Reverend Senator Sergeant Sister First Name: Middle Initial: Last Name: Email: Phone: Alt. Phone: Address:   Suite / Apt #: City: State: Select... Maryland District of Columbia Virginia Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington West Virginia Wisconsin Wyoming Zip Code: Gender: Select... Unknown Male Female The person with a mental health diagnosis is my: Grandparent Parent Sibling Significant Other Grandchild Child Friend Other Age of person with diagnosis: Select... Age 12 or under 13-18 19-21 22-29 30-39 40-49 50-59 60-69 70 or older How long have they been ill? Select... 1 year or less 2-5 years 6-10 years 11 or more years What is the diagnosis?   (To select multiple options - hold down the CTRL key while selecting) Attention Deficit Hyperactivicity Disorder (ADHD) Bi-Polar Disorder Borderline Personality Disorder (BPD) Depression Eating Disorders Emotional Disabilities Obsessive Compulsive Disorder (OCD) Panic Disorder Post-Traumatic Stress Disorder (PTSD) Schizophrenia Schizoaffective Disorder Seasonal Affective Disorder (SAD) I do not know my diagnosis Other What is your primary language? English  Spanish How did you hear about this class? Select... Family Member Friend / Co-worker Support Group NAMI Brochure NAMI Newsletter Online Newspaper Radio / TV Other Are you a NAMI MC member? Yes  No Do You Want Email from NAMI MC? Yes  No