Form Page

First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Has your teenager or child experienced any of the following?*

Anorexia nervosa

Bulimia Nervosa

Another Eating disorder

Body Dysmorphic disorder

Suicidal Ideation

Attempted suicide

Suicide

Severe levels of depression

Other severe mental health conditions

None of the Above

Does your teenager or child have a Facebook or Instagram account?*

Yes

No

How often did your teenager or child use their Facebook or Instagram account each day?*

What state do you live in?

When would be a good time to call you?

Central Time

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I Consent