Please fill out the form completely, then press ‘submit’ so that our team can get to know more about your situation before calling you back. If there is an immediacy to the crisis you face – your loved one presenting as a threat to themselves or others, please dial 911 now.

All information submitted will remain strictly confidential.

A Little About You
Your Name
Relationship to Identified Loved One (ILO)	Friend Family Member Work Associate Referent Other
Email
Home Phone
Cell Phone
Address
City
State	Your state’s 2-letter abbreviation.
Zip	Your 5 digit zip.
Intervention needed?	Yes   No
How did you hear about our work?
About Your Friend
Friend’s First Name
Marital Status	Single Married Partner Widowed Separated Divorced
Children	Number of children under 18
The individual I am concerned about is having a problem with:
	Alcohol Drugs Debt Gambling Sex Internet Disordered Eating Other
Has your friend had prior treatment for this or any other problem?
	Yes   No
If yes, specify:
Is your friend currently under the care of:
	Psychiatrist Therapist/Counselor Psychologist None
In the past year, has your friend:
	Talked of suicide Planned suicide Attempted suicide Unknown
Does your friend have any eating disorders?
	Anorexia Bulimia Other None
In the past year, has your friend:
	Expressed intent to harm another Engaged in threatening behavior Harmed another Received a notice of a restraining order Other
When we contact you, we will ask you about your payment preferences and/or insurance information if applicable.