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PLEASE NOTE ALL ANSWERS WILL BE HELD IN STRICT CONFIDENCE. Only a person with a mental health condition may request a Peer Connector. NAMI Community Peer Program does not accept referrals to the program from family, friends, or mental health professionals.
Name* (required): Email* (required): Age* (you must be 18 or older): 18 - 3030 - 4040 - 5050 - 6060 - 70Above 70
Date*: Telephone*:
Street Address:
City: Zip:
State:
Have you been hospitalized in the last year?NoYes
If yes, please tell us where:
Emergency Contact
Name (required):
Phone (required):
The following questions will help us know you better in order to make the best match possible Where did you hear about Community Peer Program? What brought you to NAMI? How would you describe yourself? What are some of your strengths? What are some of your shortcomings? Do you have a diagnosis? If not, please list some of your symptoms and/or medication side effects? In what way does your mental health affect your activities of daily living? How does your living situation impact your mental health?
List three (3) goals you would like to achieve while working with your Peer Connector?
Goal 1:
Goal 2:
Goal 3:
What are you looking for in a Peer Connector? What would you like your Peer Connector to know before you meet? Where would you like your mental health to be after four (4) months?
On a scale of 1-5, tell us how isolated you currently feel: Don't know1 ( Extremely isolated)2345 (Not isolated)
On a scale of 1-5, tell us how hopeful you are about your recovery: Don't know1 ( Not at all hopeful)2345 (Very hopeful)
What do you use for transportation?
Do you have any physical limitations, medical conditions, or dietary restrictions? If yes, please describe below:
Please add any comments or questions below:
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