Should our Chat Session End Unexpectedly, is there an email address or phone number we may reach you at?

How are you currently feeling? *  (select one) 1- I'm ok 2 - A little upset 3 - Moderately upset 4 - Very upset 5 - Extremely upset

What is your Main Concern? *  (select one) Abuse Addiction Anxiety Bullying Depression Economic Family Grief/Loss Health/Medical Relationships School Self Harm Suicide Violence

Age *

Gender *  (select one) Female Male Transgender Questioning Unknown

How did You Find Out About Crisis Chat? (select one) Friend/Family Member Counselor/Therapist School Radio/TV/Newspaper Social Media/Online Printed Materials

How did you find out about crisis chat? Other, please specify

Race- How do you Identify Yourself? *  (select one) Caucasian/White Black/African American American Indian or Alaskan Native Middle Eastern Mixed Race Prefer not to answer Other

Race- Other, please specify

Ethnicity *  (select one) Hispanic or Latino Neither Hispanic nor Latino Prefer not to answer

Do You Have Thoughts of Suicide? (select one) Yes, currently I have suicidal thoughts Recently I have had suicidal thoughts (within past 2 months) Not having any thoughts of suicide

Some visitors that use chat services may have thoughts of suicide.  If this is true for you, please complete the next six 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… (select one) a. high hope that things will change for the better. b. some hope things will change for the better. c. little hope things will change for the better. d. no hope things will change for the better.

2. I am having thoughts about suicide, but I have these thoughts... (select one) a. completely under control. b. somewhat under control. c. somewhat out of control. d. completely out of control.

3. I am having thoughts about suicide, but I am... (select one) a. very sure I can work through this. b. somewhat sure that I can work through this. c. somewhat unsure I can work through this. d. very unsure I can work through this.

4. I am having thoughts about suicide, but I am... (select one) a. sure that I can stay safe for now. b. somewhat sure I can stay safe for now. c. somewhat unsure I can stay safe for now d. very unsure I can stay safe for now

5. I am having thoughts about suicide, but I am... (select one) a. very unsure I will attempt suicide. b. somewhat unsure I will attempt suicide. c. somewhat sure I will attempt suicide. d. very sure I will attempt suicide.

6. Is this the first time you have contacted this crisis chat line? (select one) a. Yes, this is the first time b. No, this is *not* the first time