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		What are you concerned about today? *  (select one) Addictions Anxiety or Depression Bullying Death of a Loved One Eating Disorder Family Issues Financial Issues Non-Suicidal Self Injury Physical Health Physical or Emotional Abuse Relationship issues Sexual Orientation Issues Other
Other, please specify
How upset are you today? [Scale of 1–5] *  (select one) 1 - I'm doing OK 2 - A little upset 3 - Moderately upset 4 - Very upset 5 - Extremely upset
Age Range *  (select one) 0 - 12 13 - 17 18 - 24 25 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90+ Unknown
		Gender *  (select one) Male Female Transgender Questioning
How did you find out about Crisis Chat? *  (select one) Counselor or Teacher Family or Friend Internet Search Link from another website Poster, Flier or Newspaper Other
Other, please specify
If you didn't connect with us, who would you connect with? *  (select one) 911 ER Family Member or Friend Counselor, Doctor or Therapist Crisis Phone Line No One
Race – How do you identify yourself? (select one) Black or African American Alone White or Caucasian Alone American Indian or Alaskan Native Alone Asian or Asian American Native Hawaiian or Other Pacific Islander Alone Two or more of the above
Ethnicity (select one) Hispanic or Latino Neither Hispanic nor Latino
Have you ever served in the US Armed Forces? (select one) Did Not Ask No Yes
If yes to 'Have you ever served in the US Armed Forces?', please specify: (select one) Veteran Active Duty Family Member Retired Military