FOTP Mental Health Advocacy Request

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Advocate Request Entry

If you need immediate emergency assistance, please call 911, or for the Suicide and Crisis Hotline, please dial 988.

Your safety is our top priority. If you find yourself a victim of sexual violence and this is an emergency, dial 911 immediately. If you're a victim of sexual violence, you can get help 24/7 at RAINN. RAINN is the Rape, Abuse, and Incest National Network. You will immediately be connected to someone who will help you obtain the immediate resources you need. Available 24/7 1-800-656-HOPE (4673) or visit RAINN.org.

Domestic abuse/violence or relationship abuse/violence is a pattern of behaviors used by one person to maintain power and control over another in a relationship. This can include physical or mental abuse. If you are a victim of abuse and need immediate help, please call The National Domestic Abuse hotline at 1-800-799-7233.

Personal Information

Campus

Campus is required.

Name

Name is required.

Gender

Female Male

Gender is required.

Date of Birth

/ / Date of Birth cannot be a future date.

Marital Status

Single Married Divorced Widowed Dating

Marital Status is required.

Mobile Phone

Mobile Phone is required.

Email is required.

Address

Address is required.

How Can We Help?

What has caused you to seek help today

What has caused you to seek help today is required.

Anxiety, Panic, Worry, Fear

Current Concern Past Concern Never a Concern

Anxiety, Panic, Worry, Fear is required.

Anger, Bitterness

Current Concern Past Concern Never a Concern

Anger, Bitterness is required.

Depression, Sadness, Grief

Current Concern Past Concern Never a Concern

Depression, Sadness, Grief is required.

Suicidal Thoughts/Attempt, Harm

Current Concern Past Concern Never a Concern

Suicidal Thoughts/Attempt, Harm is required.

FOTP is not an emergency service. If you are currently experiencing suicidal thoughts or thoughts of self-harm please dial 988 immediately. A FOTP Advocate will reach out to you in the next 24-48 hours.

Please Understand

I understand that I am meeting with an FOTP Mental Health Advocate. This is not a therapeutic session and I will not be receiving professional counseling. I understand that after the meeting with the Advocate, I may be referred to a professional.

Please type your name in the signature field to confirm you've read, and are in agreement with, the above statement.

Waiver Signature

Waiver Signature is required.

Waiver Date

Waiver Date is required.

Submit