****Please use the form below to notify the Foundation if a suicide occurs in your agency or if you feel that someone is at risk of suicide.

Most individuals who are suicidal want help, and the suicide can be prevented by an "awareness" of the risk factors and signs.

Contact us if you feel that you need some guidance in how to handle the situation or if you feel that a professional referral needs to be made.

Your full name:
Your email address:

Your company:

From:

Agency:

Phone:

Fax:

Person being referred:

Occupation:

Address:

City/Town:

State/Prov.:

Post./Zip Code:

Country:

Reason for referral:
(Check all that apply)
Send out Suicide Awareness Packet
Mail out literature on grief
Make a referral
Need to be contacted by survivor support staff
Mail out information on training

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