Gender *

Male
Female
Unknown/Undisclosed

Age Group *

0-2
3-12
13-17
18-22
23-59
60-64
65-74
75+
Unknown

Ethnicity *

White Caucasian
Black or African American
African American (Black) and White
Other Multi-Race
Asian
American Indian or Alaskan Native and White
American Indian
Asian and White
Amer.Indian or Alaskan and Black/African American
Unknown

Contact Preference

Call
Text
Unknown

Preferred time to call or text (If known)

8am-12pm
12pm-5pm

Please indicate the reason for this referral / primary concerns. *

Depressed
Intoxicated
Experiencing psychosis
Domestic violence
Recent trauma
Other

Known Risks

Suicidal ideation
Homicidal ideation
Substance use
Weapons in the home
Dogs in the home
History of aggression toward others
Other