Lifeline Pre-Chat Survey

Pre-Chat Survey

Fields marked with an asterisk (*) are required.

Zip Code (used to connect you to a closer crisis counselor when possible): *

Name/Alias (optional):

Age (optional):

Do you identify as transgender? (optional)

Yes
No
I'm not sure
Decline to answer

If not listed, please enter your main concern (optional):

For LGBTQI+ people under the age of 25, we have an additional support option that can connect you to an LGBTQI+ trained crisis counselor. If you'd like this support, please check this box.

Do you have thoughts of suicide? *

Yes - Current (within the past 24 hours)
Yes - Recent Past (within the past two months)
No

On a scale of 1-5: How upset are you? *

1 = I'm doing OK
2 = A little upset
3 = Moderately upset
4 = Very upset
5 = Extremely upset

Your crisis counselor may request to check in with you after your conversation or contact you in case of technical difficulties. At what phone number may we reach you? (optional)

I agree to the terms of service.

ⓘ Please note that if you are using an iPhone or iPad browser to chat with us you must remain on the browser chat screen to stay connected.
If you navigate away from the chat or access a different application your connection may be lost.
Thank you for understanding.