Schedule - Suicide Prevention

Our service is only available in the United States.

City*

State*

Date of Birth*

Hidden

Age

Sex*

Orientation*

Marital Status*

Height*

Weight*

Have you received any mental health diagnoses?*

Diagnosis*

Select your diagnoses from the list below.

Anxiety disorders

Major depressive disorder

Bipolar disorder

Schizophrenia

Obsessive-compulsive disorder (OCD)

Post-traumatic stress disorder (PTSD)

Attention deficit hyperactivity disorder (ADHD)

Autism spectrum disorder (ASD)

Borderline personality disorder (BPD)

Narcissistic personality disorder (NPD)

Antisocial personality disorder (ASPD)

Generalized anxiety disorder (GAD)

Panic disorder

Social anxiety disorder

Specific phobias

Eating disorders

Insomnia disorder

Substance use disorders

Schizoaffective disorder

Delusional disorder

Dissociative identity disorder (DID)

Body dysmorphic disorder (BDD)

Hoarding disorder

Trichotillomania (hair-pulling disorder)

Excoriation (skin-picking) disorder

Other

None of the Above

Additional notes on your diagnoses

please further explain any previous diagnoses

How long have you experienced suicidal thoughts?*

Have you attempted suicide in the past?*

Does a close family member have any history of suicidal ideation or attempts?*

Has a close family member comitted suicide?*

Diet*

Which choice below best describes your current diet?

Junk Food Diet: High in calories, unhealthy fats, sugar, and salt. Typically includes fast food, processed snacks, sugary drinks, and desserts.

Western Diet: High in red and processed meat, refined grains, sugar, and saturated fats.

Low-Nutrient Diet: Low in fruits, vegetables, whole grains, and other nutrient-rich foods. Often includes processed foods and refined carbohydrates.

Meat-Centric Diet: High intake of red and processed meats, with few fruits, vegetables, and whole grains.

Standard American Diet: High in saturated fat, sugar, salt, and processed foods. Few fruits, vegetables, whole grains, and lean proteins.

Keto Diet: High-fat, moderate-protein, very low-carbohydrate diet that forces the body to burn fat for energy instead of glucose.

Omnivore: Balanced diet that includes a variety of nutrient-rich plant and animal-based foods.

Flexitarian: Mostly plant-based diet with occasional meat or animal products.

Mediterranean: High in fruits, vegetables, whole grains, legumes, fish, and healthy fats.

Vegetarian: Plant-based diet that excludes meat but may include animal products like dairy and eggs.

Vegan: Plant-based diet that excludes all animal products, including meat, dairy, and eggs.

Sleep*

how would you describe your sleep habits?

Excellent: I consistently get enough sleep and wake up feeling rested and refreshed.

Good: I generally get enough sleep and feel rested most days.

Fair: I sometimes have trouble falling asleep or staying asleep, which can leave me feeling tired during the day.

Poor: I often struggle to fall asleep or stay asleep, which can negatively impact my daytime productivity and mood.

Very poor: I frequently experience difficulty falling or staying asleep and wake up feeling exhausted.

Insufficient: I rarely get enough sleep and consistently wake up feeling exhausted and fatigued.

Exercise*

how would you describe your exercise habits?

Very active: I engage in high-intensity exercise for at least 30 minutes a day, at least five days a week.

Moderately active: I engage in moderate-intensity exercise for at least 30 minutes a day, at least five days a week. Examples include brisk walking, cycling, or swimming.

Somewhat active: I engage in light exercise for at least 30 minutes a day, at least five days a week. Examples include yoga, stretching, or walking.

Not very active: I engage in light exercise occasionally or for less than 30 minutes a day.

Sedentary: I engage in no regular physical activity or very little physical activity throughout the day.

Physically limited: I have a medical condition that limits my ability to exercise.

Sun Exposure*

how would you describe your outdoor habits?

Optimal: I get enough sun exposure to meet my body's vitamin D requirements, but I take care to avoid overexposure and sunburn.

Sufficient: I get some sun exposure most days, but I take care to avoid overexposure and sunburn.

Inadequate: I rarely get any sun exposure, or when I do, it's for very short periods of time.

Sun-sensitive: I have fair skin or a history of skin cancer, and I need to take extra precautions to avoid overexposure and sunburn.

Overexposed: I get a lot of sun exposure, often for long periods of time.

Avoiding sun exposure: I intentionally avoid sun exposure due to a personal preference or medical condition.

Social*

how would you describe your social habits?

Very social: I spend a significant amount of time socializing with friends, family, and acquaintances on a regular basis.

Moderately social: I have a moderate amount of social interaction, including regular contact with friends and family, but I also enjoy some alone time.

Somewhat social: I have some social interaction, but I also value my alone time and enjoy quiet activities like reading or watching movies.

Not very social: I have limited social interaction and prefer to spend most of my time alone or with only a few close friends or family members.

Socially isolated: I have very little social interaction and often feel lonely or disconnected from others.

Social anxiety: I have social anxiety that limits my ability to interact with others, and I find it challenging to make and maintain social connections.

Spiritual*

how would you describe your spiritual habits?

Very spiritual: I have a strong spiritual practice that involves regular meditation, prayer, or other spiritual rituals that help me connect with a higher power.

Moderately spiritual: I have a moderate spiritual practice that involves some form of regular spiritual activity, but I may not do it every day or as frequently as I would like.

Somewhat spiritual: I have some spiritual practices that I engage in occasionally, but I do not have a consistent or regular routine.

Not very spiritual: I do not have a regular spiritual practice, but I am open to exploring spiritual or philosophical ideas and concepts.

Non-spiritual: I do not engage in any spiritual practices or have any belief in a higher power or spiritual realm.

Exploring spirituality: I am exploring different spiritual practices and ideas, but I have not yet found a specific practice that resonates with me.

Alcohol*

how would you describe your alcohol use?

None

Rarely

Socially

Regularly

Dependant

Drugs*

how would you describe your drug use?

None

Rarely

Socially

Regularly

Dependant

Would you be more likely to schedule a phone call or Zoom?*

Phone Call

Zoom

Neither

How important is it that you stay anonymous?*

Unimportant	Neutral	Important

Would you agree to participate in a livestream, in which we discuss your story, while keeping your anonymity?*

Our goal is to help others with suicidal thoughts feel less alone by sharing your story.

Yes, I'd like to share my story

Would you be willing to share your story with us in person and on camera, without anonymity?*

We'd like everyone to have the chance to hear your story. Healing begins when we understand we're not alone.

Yes, I'd like to share my story in person.

Are you be interested in being paired with a trained (not a medical professional) listener who has experienced suicidal thoughts, or who has survived a suicide attempt themselves?*

Yes

Would you be interested in a service that would connect you with a trained listener (not a medical professional) who can offer support, who has experienced suicidal thoughts themselves?*

Not interested	Might be Interested	Neutral	Interested	Strongly interested

What price would you expect to pay for a service that will connect you to experienced listeners (not medical professionals) who will offer support and have experienced suicidal thoughts or survived a suicide attempt themselves?*

$20 for 20 minute call	$45 for 30 minute call	$125 for 50 minute call

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