Marcus Alert Database

Availability:

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 Information

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone number

Alternate phone number

Emergency Contact Information

Emergency contact name

First Last

Emergency contact Phone Number

Emergency contact alternate phone number

Health Information

Do 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 condition

Do you have any allergies?

Yes

If yes, please list your allergies

Other important information

Resources

Health care provider name

First Last

Health care provider phone number

Health care provider email

Mental health care providers or case workers

Medications

Stressors

Prevention and wellness process or crisis plan

Anything 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 information

Name

First Last

Relation to individual for whom you are filling out this form

Phone number

CAPTCHA

Marcus Alert Database

Contact Information

Emergency Contact Information

Health Information

Resources

Individual Completing this Form

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