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Cohort Three
This form is designed for those who are currently interested in registering for the AS+K? About Suicide to Save a Life Training of Workshop Leaders. We ask that you fill in the information below to the best of your ability. Thank you
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First Name:
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Your answer
Last Name:
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Your answer
Email Address:
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Your answer
Title:
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Your answer
Organization:
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Street Address:
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Your answer
City:
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Your answer
State:
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Your answer
Zip Code:
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Your answer
Phone Number:
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Your answer
Supervisor's Phone Number/Email (in case of emergency during training):
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Your answer
Mailing address for materials (if different from address listed above):
Your answer
In what county in SC do you reside?
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Your answer
Are you willing to provide the training a minimum of five times throughout the year?
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Your answer
Where do you plan to provide the training? (Please include county, name of organization or group, and the populations you plan to train)
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Your answer
Are you a SC Department of Mental Health employee?
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Yes
No
If you are a SC-DMH employee, please list your DMH email below:
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Previous suicide intervention trainings attended:
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Does the following statement apply to you: In the last three years, I have been directly impacted by suicide through a family member, friend, coworker, or client.
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Yes
No
Does the following statement apply to you: I have not been personally impacted by suicide in the above ways but I care about this issue and want to help.
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Yes
No
Please list any other community members and their contact information who may be interested in being a part of this training.
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