Application to Join National Suicide Prevention Lifeline: Page 1 of 8

Application to Join National Suicide Prevention Lifeline Network

This application consists of 8 pages of questions. You may pause the application at any time by clicking the button at the bottom of any page; you will be asked for your email address, to which a reminder to complete the application will be sent.

If you have questions while completing the application, please feel free to contact Carole Ludwig, Network Development Coordinator, at 212-614-5768 or cludwig@mhaofnyc.org.

I. Organizational Information (Page 1 of 8)

Name of crisis center and organization under which it operates:
Address 1:
Address 2:
City:
State:
Zip Code:
Administrative telephone:
Fax:
Organizational website URL/address:
Name, telephone number and email of person completing this application:
CEO/Executive Director:
Primary contact person and contact information (title, email, and phone number) for hotline/call center:
How long has your crisis center been operating in your community?
Number of sites requesting participation in the Lifeline Network (please identify mailing and contact information for each):

Is your crisis center participating in a local or statewide hotline network?
Yes
No
If Yes, please list here:

If you become a member of the Lifeline Network, will that affect your participation with any of the other networks in which you are currently involved?
Yes
No

Please note there are no restrictions on the number of local or national networks in which a Lifeline member can participate.

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