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.

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Virgin Islands, U.S.
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Postal code

SERVICE ELIGIBILITY & BACKGROUND

What is Your Role/Affiliation? *

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Firefighter
EMT/Paramedic
Law Enforcement
Dispatcher
First Responder Family Member
Active-Duty Military
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Active-Duty Military Family Member
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Branch of Service/ Department (if applicable)

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MENTAL HEALTH & SUPPORT NEEDS

What type of Services Are you Seeking?

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Individual Therapy
Group Therapy
Mental Resilience Coaching
Family Therapy
Peer Groups
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Have you been diagnosed with a mental health condition?

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Prefer Not to Say
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Are you currently receiving any mental health treatment?

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If yes, what type of treatment are you receiving?

Do you have a history of self-harm or suicidal ideation?

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ADDITIONAL INFORMATION

Do you have any barriers to accessing mental health care?

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Stigma
Privacy Concerns
Financial
Transportation
Resources
Scheduling
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Please share any additional information that you feel comfortable sharing

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