YouthLine Follow-Up Form

Client Information

Gender Identity

Contact First Name *

Contact Last Name

Preferred Name

Date of Birth

Age*

Primary Contact

Primary Phone Number*

Is it okay to leave messages

Comments (Extensions etc.)

Secondary Contact

Secondary Phone Number

Is it okay to leave messages

Comments (Extensions etc.)

Date of follow-up (Please don't schedule a follow-up for the same day. Please schedule 1-3 days from the original interaction) *

Preferred Times to Receive Contact (provide times between 4pm - 9pm Pacific Time 7 days a week) *

Preferred Contact Method

Alternate Contact Person

Address

City

State

Zip Code

Clinical Information

Primary Contact Issue(s)*

History of self-harm or harm to others, including previous suicide attempts(including plans, access to means, attempts, timeline)*

Did contact disclose suicidal ideation during the call/text/chat?*

Did the contact have a suicide plan at the time of call/text/chat?*

Relevant psychosocial issues (e.g., school, family, relationship issues, housing/finances/work):*

Safety Plan:*

Facility Information

Call Center Scheduling Followup

Call Center Staff Name

Call Center Information (Phone Number)

Electronic Signature: By choosing "Accept", I acknowledge that this contact has received information about YouthLine and agrees to receive a followup contact from YouthLine*