LETTER REQUEST

Recipient Information

First Name *If you are the recipient, answer for yourself.

Last Name *If you are the recipient, answer for yourself.

Pronouns: *

Gender Identity:

Mailing Address *

Apartment, suite, etc.

City *

State/Province *

ZIP / Postal Code *

Country *

Email:

What are some things you like about the recipient? *

The recipients favorite color:

Please share what's been going on: *

How would you characterize the situation? *Everyday challenge or minor setbackSignificant life challenge or mental health concernSerious mental health crisisAt risk for suicide

Does the recipient feel hopeless, alone or in despair? Like things will never get better or nobody understands? *YesNoIf you are the recipient, answer for yourself.

PURPLE NOTE PROJECT

A series of 25 notes sent over 12 months to provide ongoing support and encouragement.

Would you like to sign up the recipient? *Yes, send 25 notes over 12 months.No, send one letter.If you are the recipient, answer for yourself.

Is there anything else you'd like to tell us? *

YOUR INFORMATION

First Name *

Last Name *

Email Address *

LETTER REQUEST

Recipient Information

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