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The following is used for conversational purposes only and is optional.
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Should our chat session end unexpectedly, is there an email address or phone number we may reach you at?

Contact Info
How upset are you? [Scale of 1–5] * 
What is your main concern? * 
Other, please specify
Do you have thoughts of suicide? * 
Age *
Gender * 
How did you find out about Crisis Chat? * 
Other, please specify
Race – How do you identify yourself? * 
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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…
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...
6. Is this the first time you have contacted this crisis chat line?

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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)