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The following is used for conversational purposes only and is optional.
First Name *
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Country
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Should our chat session end unexpectedly, is there a phone number we may reach you at?

Contact Info

Age - If you are under 13, please call 1-800-273-8255.

Age *
Gender *
What is your main concern? *
Other, please specify
Do you have thoughts of suicide? *
How upset are you? [Scale of 1–5] *
Origin of Chat
Ethnicity *
How did you hear about Suicide Prevention and Crisis Services? *

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