In compliance with Va. Code Section 9.1-193(F), each locality shall establish a voluntary database to be made available to the 9-1-1 alert system and the Marcus alert system to provide relevant mental health information and emergency contact information for appropriate response to an emergency or crisis. If you are an individual with
the behavioral health illness, mental health illness, developmental or intellectual disability, or brain injury; the parent or legal guardian of such individual if the individual is under the age of 18; or a person appointed the guardian of such person, you may voluntarily provide identifying and health information concerning behavioral health illness, mental health illness, developmental or intellectual disability, or brain injury to this database. Provision of such information is completely voluntary. This information will be made available only to the 9-1-1 alert system and the Marcus alert system.
Emergency Contact Information
Please provide a description of any diagnoses or medical condition(s)
Individual Completing this Form
If you are completing this form for someone else please provide the following information