PMH Family Participant Form

  • Mental Health Track Family Program Participant Form

    Please answer any questions as completely as you can. Each participant must complete their own form. Please do not use this form for more than one person.

  • Welcome to Hanley Centers's 2-day Mental Health Track Family Education Program (MHFEP). 

    Addiction and Mental Health problems impact not only the person with the condition but also everyone around them.  This is most true and poignant when it comes to the family.  

    Hanley Center’s MHFEP runs monthly on Thursday 8:30am-4:00pm and Friday 9:00am-4:00pm and is a time for loved ones to share, learn, reflect, and experience support for themselves. 

    These two days are for you and will not involve interaction with your loved one in treatment.

    Please complete the following form. when you submit the form, you will recieve an email with more information including location, local hotel information, and arrival instructions. 

    Upon recieving this form, you will be contacted by a member of the Family Program to confirm your spot. Please do not make arrangements to attend until your spot is confirmed! Attendance is limited so please register as soon as possible. 

  • Format: (000) 000-0000.

  • Family Program Participant Agreement

  • I, {myName}, am voluntarily requesting participation in Hanley Foundation's two-day Residential Mental Health Family Education Program.

    As part of this process I attest or agree:

    1. That I have answered this form honestly to the best of my ability.

    2. That I understand this program is for me and will not involve interaction with my loved one in treatment. This includes after the program is completed in the afternoon.  

    3. That I will refrain from the use of mood altering substances including alcohol during the course of this progam. 

    4. That to maximize the value to myself and other family members, I acknowledge that I must make full participation during the Family Education program a priority. 

    5. That I am aware that a full-day attendance on both days of the program is required. Joining the Family Education program once it has already begun is not permitted. I also understand that if I miss a portion of the Family Education Program for any reason that I will not be allowed to return for the remainder of the program.

    6. That I have read and fully agree to all of the participation requirements for the Hanley Foundation Residential Mental Health Family Education Program.

  • {myName} {todaysDate}

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