Chat Registration:

The following is used for conversational purposes only and is optional.
First Name
Last Name
Postal code/Zip code  

Please answer these optional questions and agree to the terms to get started.

Should our chat session end unexpectedly, is there a phone number or email address where we may reach you?

Phone Number
What is your main concern? * 
Other, please specify
Are you having thoughts of suicide?

To enable Google Chat or SMS (text) communications please provide the following info:
Cellular Number:

(more details)  

Verification: To complete the registration, solve the CAPTCHA and click "Start".
(this additional step helps prevent malicious and automated attempts to access the site)