Marcus Alert Database Availability: Online 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. Contact InformationName First Last Address Street Address City State / Province / Region ZIP / Postal Code Phone numberAlternate phone numberEmergency Contact InformationEmergency contact name First Last Emergency contact Phone NumberEmergency contact alternate phone numberHealth InformationDo you have any of the following medical conditions (check all that apply) Health illness Mental health illness Developmental or intellectual disability Brain injury Please provide a description of any diagnoses or medical condition(s)Describe the medical conditionDo you have any allergies? Yes No If yes, please list your allergiesOther important informationResourcesHealth care provider name First Last Health care provider phone numberHealth care provider email Mental health care providers or case workersMedicationsStressorsPrevention and wellness process or crisis planAnything else that would be helpful for a responder to know in order to assist you?Individual Completing this Form If you are completing this form for someone else please provide the following informationName First Last Relation to individual for whom you are filling out this formPhone numberEmail Consent(Required) I agree.I understand and acknowledge that I am under no obligation to provide any of the requested information and that by filling out this form I am doing so completely voluntarily. I further understand that any information that I submit will be shared with agencies of the County of Henrico, including the Henrico County Police Division, and the Henrico County Fire Division. I further understand that this information may be used and relied upon by first responders and other individuals responding to a call for service. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
