Form Page

First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Has your teenager or child experienced any of the following?*

Attempted suicide

Suicide

Severe levels of depression

Other severe mental health conditions

None of the Above

Does your teenager or child have a Facebook or Instagram account?*

Yes

No

How often did your teenager or child use their Facebook or Instagram account each day?*

What state do you live in?

When would be a good time to call you?

Central Time