Hope to Alaska Connection Form
Your information is protected and kept confidential.

Complete this form to get connected to counseling through Hope to Alaska.

Please be patient - our response times have increased with additional requests - but we are working hard to contact everyone as quickly as possible.

***If you're having current thoughts of harming yourself or someone else, please go to the nearest emergency room or call 911 immediately***
Email *
First Name *
Last Name *
Phone number *
What is your age? *
If you're under 18 years old, please provide name of legal guardian or parent.
What's your marital status? *
What's your gender? *
Please check all that apply: *
Required
I'm looking for... *
Select your preferred counseling center *
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