Safety Net Program
Self-enrollment form to receive follow-up phone calls or texts from Dial Help, with the goal of helping you access professional treatment or counseling services, and supporting you in staying stable until you do.
DO NOT FILL OUT THIS FORM FOR SOMEONE ELSE
Because of consent issues, you may HELP someone else sign up by filling this form out WITH them, but DO NOT fill it out on your own for someone else.
First Name, Last Initial *
Date of Birth
Phone Number *
County *
What issue(s) are you enrolling for help with? *
Required
Would you prefer phone calls or texts from Dial Help? *
IF you chose phone calls, can we leave a standard message on your voicemail indicating that Dial Help staff called? *
IF you chose phone calls, can we leave a standard message if someone else answers, indicating that Dial Help staff called? *
Please initial and date below to indicate your consent to receive Safety Net Program services. We will also request verbal consent during our first call or text. *
Did someone help you fill out this form? If so, who helped you and what is their relationship to you? *
NOTES ON THE PROGRAM
- We will help you determine your eligibility during your first contact with Dial Help

- Our goal is to help you access counseling or other needed services, and support you in staying safe until then

- We offer emotional support, connection to resources, and risk assessment

- If you do not answer calls/texts five times in a row, Dial Help will automatically un-enroll you from the program

- You can request to re-enroll at any time by filling out this form again, calling 800-562-7622, or texting 906-356-3337
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