Voluntary Mental Health Database (Marcus Alert)

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 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 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.

By submitting your information, you agree that you voluntarily authorize its release to emergency responders.

Marcus Alert Voluntary Database Registration Form

The information requested below is for the person who is associated with the Mental Health information being submitted
First Name*
Last Name*
Street Address*
Gender
City*
State*
Zip Code*
Home Phone Number
Cell Phone Number
T.T.Y. Number if Applicable
Health Information
Do you have any of the following medical conditions?
1. Health Issues
2. Mental Health Issues
3. Developmental or Intellectual Disability
4. Brain Injury
(Check all that apply)
Please explain any diagnoses or medical condition(s)
Do you have any allergies?
1. Yes
2. No
If yes, please provide a list of allergies
Please provide a list of medications being taken
Please explain any stressors that need to be noted
Please explain any prevention and wellness or crisis plan that is in place
Please provide any additional Information you would like to share with emergency services in the event you call 911 for assistance.*
Emergency Contact Information
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Phone Number
Emergency Contact Alternate Number
Relationship to the person associated with this record
(Mother, Father, Grandparent, Sibling, Caregiver, Friend, etc.)
Health Care Provider Information
Providers First Name
Providers Last Name
Providers Phone Number
Providers Email Address
Mental Health Care Provider (Case Worker)
Mental Health Providers First Name
Mental Health Providers Last Name
Mental Health Providers Phone Number
Mental Health Providers Email Address
Individual Completing the Form
If you completed this form for someone else, please provide your information below.
First Name
Last Name
Phone Number
Email Address
Relationship to the person associated with this record
Consent *
By checking this box you acknowledge agreement with the statement below.
1. 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 Henry and the City of Martinsville. I further understand that this information may be used and relied upon by first responders and other individuals responding to a call for service.

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1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Voluntary Mental Health Database (Marcus Alert)

Marcus Alert Voluntary Database Registration Form

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