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Required format:

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Suicide Prevention TA Request Form

Returning?

A A A

Thank you for your interest in Suicide Prevention!

The Injury and Violence Prevention Section uses a public health approach to prevent suicides by supporting and coordinating state-funded suicide prevention activities and state suicide prevention plan, providing technical assistance, training, and data to support community-based prevention programs.

To request technical assistance, speaker, training, or other support, please fill out the form below. Someone will follow up with you within 10 business days.

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org.

Date:

M-D-Y

First and Last Name:

* must provide value

Organization Affiliation, if applicable:

If you are from a government agency, please include the division, program and/or tribe you represent:

Role, Title or Position:

Email:

Phone number:

Please describe your request:

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Which of the following best describes your request? (select one)

Mental health or suicide prevention training

Postvention training and/or support (What to do after a loss)

Data request or questions on interpreting data

Questions related to 988

Questions related to the Suicide Prevention State Taskforce

Other

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Which training(s) are you interested in?

QPR

SafeTALK

ASIST

Counseling on Access to Lethal Means (CALM)

Kognito

Other

I'm not sure

Some programs and program trainers require a fee or an honorarium for trainings. These fees can range between $200 and $2000 depending on a variety of factors. Costs will be discussed during the scheduling process and, in some cases, fees can be completely waived or greatly reduced. Are you able to provide a fee or honorarium if required? Please choose one.

Unable to provide a fee or honorarium

Not sure if able to provide a fee or an honorarium

Can provide a fee or honorarium, unsure of amount

Can provide the full fee or honorarium

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What particular communities is this request associated with? (Please include region, audience, or other considerations for accessibility. This helps us connect you with someone best suited to respond to your request.)

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What is the timeline for this request? (If you need a response by a particular date, or if you have an established training or meeting date already determined, please highlight that information here.)

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Please share any additional information or comments:

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How did you hear about this service?

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