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Do you live in Chautauqua County, NY?* Do you live in Chautauqua County, NY?* Yes No

If no, what county do you live in?

Have you experienced a suicide loss? Have you experienced a suicide loss? Yes No

If yes, has it been at least 2 years since your loss? If yes, has it been at least 2 years since your loss? Yes No

If yes, when? Connection to you?

Have you survived a suicide attempt? Have you survived a suicide attempt? Yes No

If yes, when?

What are you interested in?* (check all that apply) What are you interested in?* (check all that apply) Grief support after suicide loss (virtual only) Healing conversations with a loss survivor 10-week Suicide Loss Support Group (virtual, offered three times per year) Funeral planning support Resources for healing Presenting my story or providing training Volunteering at community events Becoming an Alliance member and attending planning meetings (4 per year) Suicide prevention training Bereavement Support Group co-facilitation (must meet requirements) Joining the Sudden Loss Care Team – CHQ County (Scan QR code on SLCT page to apply) Other (please describe)

Other Interest

Name (if you'd like us to contact you)

Phone Number

Email Address (if you'd like us to contact you)

Preferred Contact Method Preferred Contact Method Phone Email Text

Additional Information – Tell us more about your situation or interest. Example: Share how we can help you, your connection to suicide prevention, why you're interested in volunteering, or any other details you'd like us to know.