QPR Interest Form - United General District 304

Organization Name*

Contact Name*

First Last

Contact Email*

Phone

Length of Class*

QPR can be offered as a 60-minute or 90-minute training. The 60-minute version includes a presentation and Q&A portion. The 90-minute version includes the same content as the 60-minute version with additional time for supplemental slides, discussion, and/ or scenario activities. I would prefer the following length of time for the training:

60-minute training
90-minute training
Other

Please provide additional information on the length of training*

I am interested in the following training format:*

Virtually over Zoom
In person

Where would you like your training class(es) to be held?*

QPR training classes at our facility are held in the Wellness Center to the left of the main hospital entrance located at 2000 Hospital Dr., Sedro-Woolley.

Our facility on the Sedro-Woolley hospital campus
Your facility or other location

Location where the class(es) will be held:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Estimated number of participants to be trained*

Due to COVID-19 considerations, there is a maximum of 10 participants for in-person classes. If you have more than 10 people to be trained, we will work with you to determine the number of classes to be scheduled.

What days are convenient for your organization? (check all that apply)*

Weekdays (Monday-Friday)
Weekends (Saturday-Sunday)
I'd like to request a specific date
Other

What date(s) would you prefer?*

Other (please provide more info):*

What times are convenient for your organization? (check all that apply)*

Mornings (before 12pm)
Afternoons (between 12pm and 5pm)
Evenings (after 5pm)
I'd like to request a specific time
Other

What time(s) would you prefer?*

Other (please provide more info):*

QPR (Question, Persuade, Refer) Suicide Prevention Training Interest Form for Organizations