I need help!
Problems at school? No place to sleep? Family driving you crazy? Frustrated? Angry? Fearful? Alone? Depressed? Anxious? LET US HELP! We will respond to you within 24 hours.

IF THIS IS AN EMERGENCY, PLEASE CALL 9-1-1. If you are considering hurting yourself or need to talk to someone right away, please call 1-800-273-TALK (8255).

What is your name?
If you prefer to remain anonymous for now, please just say so. Or, you can use a nickname.
Your answer
How old are you?
Miami Bridge serves youth ages 10-17. If you are over 18, we may be able to help with a referral to one of our community partners.
What is your phone number?
If you do not have a phone number where we can reach you, please write "none". Please give us at least one way to reach you.
Your answer
What is your email address?
If you do not have access to an email address, please write "none". Please give us at least one way to reach you.
Your answer
What is your zip code?
Your answer
What is the best way for us to reach you?
What issues are you facing?
Required
Are you taking any medications currently?
Is there anything else you would like us to know at this time?
Your answer
What languages do you speak?
Que idioma hablas?
Required
How did you hear about us?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms