Concerned Party Form

Who is the deployment for?

Who’s filling this form out?

Your Phone Number

Multiple items that we will accept; Photo of DD214 with redacted social security #, License with Veteran Status on it, Veteran ID card, SF15 , Military ID, DEERs ID card, Photo of Disabled Veteran License Plate, Anything that shows accurate military service. If you are a GOLD STAR FAMILY- Please just submit photo of service member in uniform. (ALL ITEMS SUBMITTED HAVE TO BE LEGIBLE TO READ)

First Name (of whom the deployment is for)

Last Name (of whom the deployment is for)

Verification Veteran Affairs Member ID # Verification Department of Defense ID # Veteran's Date of Birth Veteran's Phone Number Veteran's Branch of Service Current Spouse's Name First Name Last Name Spouse's Date of Birth Spouse's Phone Number Children(s) Name(s) and Age(s) Veteran's Current Address Address

APT # City

State

Zip Code

Is there a gate code? If so, please enter it below Reason for Deployment?

ADDITIONAL INFORMATION NEEDED FOR THE VETERAN RESPONSE TEAM (VRT). IF THEY ARE ACTIVELY TRYING TO COMMIT SUICIDE STOP WHAT YOU ARE DOING AND CALL 911! Suicidal thoughts or actions present?

Does the veteran or family member live in a gated community?

Does the Veteran or Spouse own weapons?

Are there guard dogs or animals on property?

Please note any information received and collected on this application will be kept private and confidential.

By selecting yes (below), you are indicating that you have filled out the information above to the best of your knowledge and understand we will use this information to contact you and the Veteran or their family. Additionally, you understand and agree to all that is asked and stated in this application. All information and any treatments will be kept confidential. Once your paperwork is filled out and submitted, then we will be in touch with you if we have to be. Please note if you are a concerned party, we will not share any information with you about the Veteran and their family member after you submit this application. The person filling this application out is doing so because they feel there is a need for our services and understand that they are permitting us to go to the addresses listed above to check on the concerned party. The applicant's name(s) will be released to the Veteran and their family if asked. You will receive a copy for your records. Please also note that there is not a timeline on how fast the Response Team Member will be deployed to check on the Veteran and their family member. We will disclose information collected to authorities if needed.

Do you agree

Full Name

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