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The following is used for conversational purposes only and is optional.
First Name *
 
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Age *
What is your gender identity (how do you define yourself)? * 
What is your race (how do you define yourself)? * 
What is your main concern? * 
If other, please clarify:
Do you have thoughts of suicide? * 
On a scale of 1-5: How upset are you? * 
Your crisis counselor may request to check in with you after this conversation. At what phone number or email address may we reach you? (Optional)
Is this the first time you have contacted this crisis chat line?
How did you find out about crisis chat?
If other, please clarify:
Some visitors that use chat services may have thoughts of suicide.  If this is true for you, please complete the next five questions and then wait for the next available chat specialist.

If you are not having thoughts of suicide, please skip the next six questions and wait for the next available chat specialist. 
1. I am having thoughts about suicide, but I have…
2. I am having thoughts about suicide, but I have these thoughts...
3. I am having thoughts about suicide, but I am...
4. I am having thoughts about suicide, but I am...
5. I am having thoughts about suicide, but I am...


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