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] *  (select one) 1 - I’m doing OK 2 - A little upset 3 - Moderately upset 4 - Very upset 5 - Extremely upset
		What is your main concern? *  (select one) Addictions Anxiety Bullying/Problems in School Depression Eating Disorder Family Issues Financial Issues Physical and/or Emotional Abuse Physical Health Relationship Issues/Violence Self Harm Sexuality Other
Other, please specify
Do you have thoughts of suicide? *  (select one) Yes – Current (within the past 24 hours) Yes – Recent Past (within the past few days) No
Age *
		Gender *  (select one) Male Female Transgender Questioning
How did you find out about Crisis Chat? *  (select one) Counselor or Teacher Family or Friend Internet Search Link from another website Poster, Flier or Newspaper Other
Other, please specify
Race – How do you identify yourself? *  (select one) Black or African American Alone White or Caucasian Alone American Indian or Alaskan Native Alone Asian or Asian American Native Hawaiian or Other Pacific Islander Alone Two or more of the above Prefer not to answer
Ethnicity *  (select one) Hispanic or Latino Neither Hispanic nor Latino Prefer not to answer
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