Application to Join the National Suicide Prevention Lifeline

1. Organizational Information

6% of survey complete.

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* 1. Name of crisis center and organization under which it operates:

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* 2. Mailing Address:

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* 3. Physical address (if different):

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* 4. Administrative telephone number:

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* 5. Fax:

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* 6. Web site address:

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* 7. Name of person completing form:

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* 8. Title of person completing form:

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* 9. E-mail address of person completing form:

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* 10. Phone number of person completing form:

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* 11. Crisis/Hotline Director:

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* 12. How long has your crisis center been operating in your community?

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* 13. Number of sites requesting participation in the Lifeline Network (please identify mailing and contact information for each):

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* 14. Is your crisis center participating in a local or statewide hotline network?

Yes

No

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* 15. If "Yes," please list here:

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* 16. If you become a member of the Lifeline Network, will that affect your participation with any of the other networks in which you are currently involved?

Yes

No

Other (please specify)