Gatekeeper Training Attestation Form – Gizmo 4 Mental Health

I hereby attest that the below mentioned site/organization has completed a best practice youth mental health or suicide prevention gatekeeper training for the Trusted Adults in this site/organization, in accordance with the “Requirements Prior to Curriculum Implementation” found on the Gizmo 4 Mental Health website.

Name of authorized administrator attesting to this:
First Last
Administrator Title
Administrator Email
Name of Organization
Organization Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Name of person completing form:*
First Last
Title of person completing form
Email of person completing form*
Contact Phone
Are you are coordinating implementation with your AFSP State Chapter?
- Yes
- No
Type(s) of Gatekeeper Training utilized:
Date(s) of Training(s) held:
Types of staff trained (i.e. administrative assistants, cafeteria workers, bus drivers, custodians, Principals, Directors, Social Workers, etc.):
Total number of staff trained:

For more information or assistance, contact info@gizmo4mentalhealth.org.