If you or a loved one has been impacted by the recent LA fires, we're here for you.
Please complete this form, and our team will connect you with available resources, support networks, and assistance tailored to your needs.
Country
- Afghanistan
- Albania
- Algeria
- American Samoa
- Andorra
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- Armenia
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- Belize
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- Bolivia
- Bosnia and Herzegovina
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- British Indian Ocean Territory
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- Burkina Faso
- Burundi
- Cambodia
- Cameroon
- Canada
- Cape Verde
- Cayman Islands
- Central African Republic
- Chad
- Chile
- China
- Christmas Island
- Cocos (Keeling) Islands
- Colombia
- Comoros
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- Congo, The Democratic Republic of the
- Cook Islands
- Costa Rica
- Cote D"Ivoire
- Croatia
- Cuba
- Cyprus
- Czech Republic
- Denmark
- Djibouti
- Dominica
- Dominican Republic
- Ecuador
- Egypt
- El Salvador
- Equatorial Guinea
- Eritrea
- Estonia
- Ethiopia
- Falkland Islands (Malvinas)
- Faroe Islands
- Fiji
- Finland
- France
- French Guiana
- French Polynesia
- French Southern Territories
- Gabon
- Gambia
- Georgia
- Germany
- Ghana
- Gibraltar
- Greece
- Greenland
- Grenada
- Guadeloupe
- Guam
- Guatemala
- Guernsey
- Guinea
- Guinea-Bissau
- Guyana
- Haiti
- Heard Island and McDonald Islands
- Holy See (Vatican City State)
- Honduras
- Hong Kong
- Hungary
- Iceland
- India
- Indonesia
- Iran, Islamic Republic Of
- Iraq
- Ireland
- Isle of Man
- Israel
- Italy
- Jamaica
- Japan
- Jersey
- Jordan
- Kazakhstan
- Kenya
- Kiribati
- Korea People's Democratic Republic
- Republic of Korea
- Kuwait
- Kyrgyzstan
- Land Islands
- Lao People's Democratic Republic
- Latvia
- Lebanon
- Lesotho
- Liberia
- Libyan Arab Jamahiriya
- Liechtenstein
- Lithuania
- Luxembourg
- Macao
- North Macedonia
- Madagascar
- Malawi
- Malaysia
- Maldives
- Mali
- Malta
- Marshall Islands
- Martinique
- Mauritania
- Mauritius
- Mayotte
- Mexico
- Federated States of Micronesia
- Moldova, Republic of
- Monaco
- Mongolia
- Montenegro
- Montserrat
- Morocco
- Mozambique
- Myanmar
- Namibia
- Nauru
- Nepal
- Netherlands
- New Caledonia
- New Zealand
- Nicaragua
- Niger
- Nigeria
- Niue
- Norfolk Island
- Northern Mariana Islands
- Norway
- Oman
- Pakistan
- Palau
- Palestinian Territory, Occupied
- Panama
- Papua New Guinea
- Paraguay
- Peru
- Philippines
- Pitcairn
- Poland
- Portugal
- Puerto Rico
- Qatar
- Reunion
- Romania
- Russian Federation
- Rwanda
- Saint Helena
- Saint Kitts and Nevis
- Saint Lucia
- Saint Pierre and Miquelon
- Saint Vincent and the Grenadines
- Samoa
- San Marino
- Sao Tome and Principe
- Saudi Arabia
- Senegal
- Serbia
- Seychelles
- Sierra Leone
- Singapore
- Slovakia
- Slovenia
- Solomon Islands
- Somalia
- South Africa
- South Georgia and the South Sandwich Islands
- Spain
- Sri Lanka
- Sudan
- Suriname
- Svalbard and Jan Mayen
- Eswatini
- Sweden
- Switzerland
- Syrian Arab Republic
- Taiwan
- Tajikistan
- Tanzania, United Republic of
- Thailand
- Timor-Leste
- Togo
- Tokelau
- Tonga
- Trinidad and Tobago
- Tunisia
- Turkey
- Turkmenistan
- Turks and Caicos Islands
- Tuvalu
- Uganda
- UK
- Ukraine
- United Arab Emirates
- United States
- United States Minor Outlying Islands
- Uruguay
- Uzbekistan
- Vanuatu
- Venezuela
- Vietnam
- Virgin Islands, British
- Virgin Islands, U.S.
- Wallis and Futuna
- Western Sahara
- Yemen
- Zambia
- Zimbabwe
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SERVICE ELIGIBILITY & BACKGROUND
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- Firefighter
- EMT/Paramedic
- Law Enforcement
- Dispatcher
- First Responder Family Member
- Active-Duty Military
- Veteran
- Active-Duty Military Family Member
- Veteran Family Member
- Community Supporter/Advocate
- Other
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MENTAL HEALTH & SUPPORT NEEDS
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- Individual Therapy
- Group Therapy
- Mental Resilience Coaching
- Family Therapy
- Peer Groups
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- List is empty.
- Yes
- No
- Prefer Not to Say
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- List is empty.
- Yes
- No
- Prefer not to say
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- List is empty.
- Yes
- No
- Prefer not to say
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ADDITIONAL INFORMATION
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- Stigma
- Privacy Concerns
- Financial
- Transportation
- Resources
- Scheduling
- Something Else
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