NAMI Connection Recovery Support Group
Facilitator Application
Michigan Training
September 28-30th in Livonia, MI
Name___________________________________________________________________
Address_________________________________________________________________
City/State/Zip ____________________________________________________________
Phone (H)____________________Cell___________________(W)__________________
Email___________________________________Fax_____________________________
Best time to call_________________________________________________________
Reference (Name and email or 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 no, are you willing to join? Yes _____ No _____
Have you ever been convicted of a felony? Yes _____ No _____
If yes, please explain:
Please tell us why you want to be a NAMI Connection Recovery Support Group Facilitator:
Job Requirements:
Ÿ Willingness to undergo training and to adhere to fidelity to the NAMI Connection Recovery Support Group model
Ÿ to adhere to fidelity to the NAMI Connection Recovery Support Group model is required
Ÿ Commitment to perform weekly support groups for a minimum of one year
Ÿ Ability to provide group participant data as required
Ÿ Willingness to identify potential new facilitators from their support groups
Ÿ Positive regard for, or personal experience with mutual support
Ÿ Be or become a member of NAMI
Availability to co-facilitate NAMI Connection Groups (Check all that apply):
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Do you have your own transportation? Yes __ No__
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:
1. Do you
have any dietary restrictions or food allergies? If so please specify.
2. Do you need any special accommodations that we should be aware of? If so please specify.
3. Will you be requiring overnight accommodations for Thursday night?
Yes_____ No_____
4. Do you have transportation? Yes____ No____*
* If yes, would you be willing to transport other participants? Yes____ No____
q I
have read and understand the NAMI Recovery Support Group Facilitator
job
requirements.
___________ (initial)
q I
understand that my attendance at Facilitator Training does not guarantee that I
will be certified as a NAMI National Recovery Support Group Facilitator.
___________ (initial)
q 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.
________________________________________________
(Date) (Signature)
PLEASE FILL OUT BY September 1, 2007 AND RETURN TO:
NAMI Michigan
c/o Leslie Sladek
4989 W Beeman Rd
Empire, MI 49630