QPR Booklet Request Form

Mid-Valley Suicide Prevention Coalition QPR Booklet Request Form

The Mid-Valley Suicide Prevention Coalition is excited to be able to provide QPR books for trainings in Marion or Polk Counites. These booklets we purchased with a one-time grant from the Unrien Foundation. The goal of this project, is to help reduce barriers to QPR trainings so that everyone has the opportunity to learn more about suicide prevention. Please fill out the following form to submit a request for Question, Persuade, Refer (QPR) booklets. Please note that filling out this form does not guarantee you will receive booklets. The booklets will be distributed on a first come, first serve basis. A representative will reach out to you shortly to follow-up on this request.
Name

First NameLast Name
Agency
Email
example@example.com
Phone Number
Please enter a valid phone number.
QPR Training Locaiton

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
QPR training date

MonthDayYear
Date
Number of QPR Booklets Needs
language of the QPR training
Please tell us about your training:

The training will be free to attend.The training will be low-cost to attend (under $20 per person).The training will cost over $20 per person to attend.The training will be open for community members to attend.The training will target a specific group/not open for community attendance.
Please tell us about the training participants. Who will participate in the QPR training? (Ex: health care, education, government, youth etc.)
Please note that we will ask you to fill out a post-training summary. Click HERE for the link to the summary form. This quick summary will help us report back to our funders on how the booklets were distributed. MVSPC has a standard QPR pre/post test evaluation form that we are happy to share with you to use for the training. The use of the standard evaluation form is optional. You will receive an email confirming your QPR booklet request that also has the post training summary and the link to the optional Pre/Post training evaluation form.
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Mid-Valley Suicide Prevention Coalition QPR Booklet Request Form