Page 1 of 5 Facilitator Application CA Training Note: Please fill out the application completely. Date of the training: City where training will be held: Contact Information: Last Name: First Name: M.I.: Street Address: City: State: Zip: Phone: ( ) Cell: ( ) Email: NAMI Affiliate: Reference from your local NAMI Leader (Name and Email/Phone): (Please note: Your reference should be someone who knows you well enough to recommend that you be trained to become a facilitator.) Are you a member of NAMI? Yes No If yes, Local Affiliate: If no, are you willing to join? Yes No Have you ever been convicted of a felony? Yes No If yes, please explain: 1. How do you define recovery? How are you doing in recovery right now? Please explain:
Page 2 of 5 2. Do you feel you have come to terms with your mental illness? Please explain: 3. Do you feel you can offer support in the manner that you have been supported? Please explain: 4. Are you comfortable talking about your experiences as a person living with mental illness and what you have learned? Please explain: Availability to co-facilitate NAMI Connection Groups (Check all that apply): Morning Afternoon Evening Monday Tuesday Wednesday Thursday Friday Saturday Sunday Do you have your own transportation? Yes No Do you have access to Public Transportation? Yes No Are you willing to travel? Yes No If yes, how far: 5-10 miles 11-20 miles More than 20 miles What language(s) other than English do you speak fluently?
Information needed, should you be selected to attend training. Page 3 of 5 1. Do you have any dietary restrictions or food allergies? Yes No If yes, please specify: 2. Do you need any special accommodations that we should be aware of? Yes No If yes, please specify: 3. Do you have transportation to the training? Yes No If yes, would you be willing to transport other participants? Yes No If yes, initial to allow sharing of your personal contact information for carpooling reasons only. Initials: If no, are you requesting to carpool with another participant? Yes No 4. If I live within 30 minutes of the training site, I intend to drive to and from home each day. Yes No 5. If you intend to commute each day, will you be staying for the dinner meals? Yes No Job Requirements: Willingness to undergo training and to adhere to fidelity to the NAMI Connection Recovery Support Group model. To adhere to fidelity to the NAMI Connection Recovery Support Group model is required. Commitment to perform support groups for a minimum of one year. Ability to provide group participant data as required. Willingness to identify potential new facilitators from their support groups. Positive regard for or personal experience with mutual support. Be or become a member of NAMI. I have read and understand the NAMI Recovery Support Group Facilitator job requirements. (Initials) I understand that my attendance at Facilitator Training does not guarantee that I will be certified as a NAMI National Recovery Support Group Facilitator. (Initials) If selected to attend - Attending the NAMI Recovery Support Group Facilitator Training, and receiving certification as a facilitator, I acknowledge that I am making a commitment to facilitating a support group once a week for a one year period. Signature Print Name Date
Page 4 of 5 MENTOR AGREEMENT I agree to be at each session of the workshop on time. Please understand that if you are excessively late to sessions or leave more than 30 minutes early on Sunday you may jeopardize your participation in the workshop and a teacher certificate may not be issued to you. I understand that participation in this training does not guarantee that I will become a certified NAMI facilitator. Trainees must demonstrate the qualifications needed to become a good NAMI facilitator by the end of the training. The first day of training provides an opportunity for trainees to assess their basic qualifications for being a facilitator. Any concerns should be brought to the trainers attention. Attendance at a training does not guarantee teacher certification. I agree to behave in a professional manner. To be described as not engaging in illegal drug use, or to be sexually or romantically intimate with participants at the training unless I am have been in a committed relationship with that person prior to the training. This also includes not behaving in a way that is disrespectful, violent or aggressive. I agree to notify Lynn Cathy at (916) 567-0163 if I must cancel. Prompt notification of a cancellation enables us to invite another participant. Last minute cancellations often mean that NAMI still must pay the hotel and food expenses for a participant. I agree to facilitate the Connection group for at least 1 year. It is understood that unexpected situations may occur in which flexibility in this policy will be needed. I agree to facilitate Connection groups according to the established NAMI Operating Policies I agree to I agree to provide group participant data to NAMI National or to the local affiliate for them to report. Signature of Applicant Print Name Date
Page 5 of 5 Emergency Information: Contact Name: Relationship to you: Telephone numbers (2 preferred): Do you have a cell phone number we can reach you at that weekend? Carpool: I give my permission for Lynn Cathy to disclose my email and/or phone number to parties interested in carpooling. Yes No (Requests to be made no later than 2 weeks before a training.) Signature: Print Name: Date: Thank you for your application. YOU WILL BE NOTIFIED BY EMAIL IF YOU HAVE BEEN SELECTED TO ATTEND. NOTE: The deadline for all applications is two weeks before a training is scheduled however please remit as soon as possible as trainings fill quickly. Thank you. Please Mail, Fax* or Email to: Lynn Cathy, Family & Peer Programs Supervisor 1851 Heritage Lane, Suite 150 Sacramento, CA 95815 Phone: (916) 567-0163 x 101 Fax: (916) 567-1757 Email: lynn@namica.org *Please follow up faxed applications with a phone call or email to confirm receipt.