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The following is used for conversational purposes only and is optional.
First Name
Last Name
Postal code/Zip code  
Should our chat session end unexpectedly, is there an email address or phone number we may reach you at?
Contact Info
What is your main concern? * 
Other, please specify
Do you have thoughts of suicide? * 
How upset are you? [Scale of 1–5] * 
Age *
Gender * 
How did you find out about Crisis Chat? * 
Other, please specify
If you didn’t connect with us, who would you connect with? * 
Race – How do you identify yourself?
Origin of Chat

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(this additional step helps prevent malicious and automated attempts to access the site)