Do you want me to visit your high school?
I lost my son, Charles to suicide while he was going through withdrawal and have since become a speaker on the subjects of mental illness, suicide and addiction at conferences, colleges and high schools. Please list your high school if you'd like me to reach out.
1. Please list your name here (optional)
Your answer
2. Please list your email here (optional)
Your answer
3. What is the name of the high school you wish to recommend? (Please list only one. Use the form again to list another if you have more than one.) *
Your answer
4. What is the address of this high school? (High schools outside the US are acceptable) *
Your answer
5. What is the name of the Headmaster/Head of school/Principal? *
Your answer
6. What kind of school? *
Required
7. If you know it, what is the email of the headmaster/head of school/principal?
Your answer
8. If you know it, what is the phone number of the office of the headmaster/head of school/principal?
Your answer
9. If other in 6 above, please describe
Your answer
10. Do you have a relationship with the headmaster/principal of this school? And if so, offer details and let me know if I can use your name and this information in the correspondence. *
Your answer
11. In your opinion, is it more important to lead with substance misuse or suicide prevention?
12. If there is anything you'd like to add, you can comment here.
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of annemoss.com. Report Abuse