NAMI Northern Virginia Facilitator Application Form

NAMI Northern Virginia Facilitator Application Form

NAMI Northern Virginia is the local affiliate of the National Alliance on Mental Illness (NAMI). Our programs serve the counties of Arlington, Fairfax and Loudoun and the cities of Alexandra, Fairfax, and Falls Church.

Name:
Address:
Phone: / Alternate Phone:
E-mail:
Best time to call:
Have you attended Connection Support Group? (yes or no)
Have you even been convicted of a felony? (yes or no)
If yes, please explain:
Are you currently a NAMI Northern Virginia member? (yes or no)
If not, are you willing to become a NAMI Northern Virginia member? (yes or no)
List other NAMI programs that you have participated in and your role in the program (i.e. facilitator, presenter, participant, etc.)

Do you under the following commitments (please initial if you agree):

Are you willing to co-facilitate aConnection Support Group meeting monthly for a minimum of one year after training?
Are you willing to undergo training and adhere to the fidelity of the NAMI Connection Support Group model?
Are you willing to continue working towards personal recovery?
Do you understand that this is a volunteer opportunity?
Do you understand the requirement to provide group participant data?
Are you willing to identify potential new facilitators from the support group?
Are you willing to have a positive regard for, or personal experience with mutual support groups?
Be or become a member of NAMI?

Availability to facilitate (please check all that apply):

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Morning
Afternoon
Evening

1.Why do you like to become a Connection Support Group facilitator?

2. Why do you feel the time is right to give back through this educational volunteer opportunity?

3. Please share where you think you are in your own recovery and why you would be able to model successful recovery to others wishing to maintain or work towards their own level of recovery.

4. What is one message about mental health that you would like to share with the world?

Additional comments:

Presenter training is provided by NAMI Northern Virginia, NAMI Virginia, and a grant from Virginia DBHS.

Please send completed applications to NAMI Northern Virginia’s Program Coordinator, Esther Lee:

Email:

Mail: NAMI Northern Virginia, P.O. Box 8693, Reston, VA., 20195

Phone: (571) 458-7310

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For staff use only:

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