Random Acts + TWLOHA: Creating a Resource Database for the #SPNFamily Crisis Support Network

Random Acts is partnering with To Write Love on Her Arms (TWLOHA) to identify mental health resources, professional treatment options, and support groups in local communities across the U.S., and internationally. Your recommendations will serve as a starting point for our team to connect people to the help they need and deserve.

We're asking you to provide some basic information about yourself and then we'll ask you a few questions about your recommendation. Provide as much information as you can, but it's okay if you have to leave some portions blank.

We greatly appreciate your help in this project!

* 1. Tell us about you!

* 2. What is your age?

The next set of questions is to provide information about your recommendation.

Please note, if you have more than one recommendation, please complete the recommendations one at a time.
If you are unsure about a service offered, or specialty, feel free to leave a portion blank. But, the more information we have the better!

* 3. Please provide us with information about your Mental Health Resource Recommendation

* 4. Please provide us with a contact for this resource

* 5. Please select the descriptions that fits your recommendation. You may choose as many that apply.

* 6. Are they accepting new clients?

* 7. Please describe the main mission or purpose of the recommendation.

* 8. If the recommended resource offers counseling services, please indicate the total number of licensed counselors, individuals working toward licensure, and any other credentials.

* 9. Please briefly describe any personal experience you've had with this recommendation.**
If you are a representative or employee of the resource recommended, please disclose that here.

* 10. Please check what type of services are offered. You may select as many that apply.

* 11. Please indicate if the provider has any specialties in treating the following:

* 12. Do they offer any financial assistance or sliding scale for clients? Please choose any options that are offered.

Thank you for submitting your mental health provider recommendation! We're so grateful to have you joining us in building this network.

Please feel free to complete the survey as many times as you'd like with additional recommendations. 

* 13. Is there any additional information that you'd like to share with us about this recommendation?