COVID-19 Help Form

COVID-19 Help Form

For veterans, family members and caregivers
The Be Connected program is here to help.

If you are a veteran, caregiver or family member and need help and support to access resources, please complete this brief form. A member of the Be Connected team will follow up with you within 3 business days.
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Are you a (check all that apply)?:

VeteranFamily MemberCaregiverOther
County:

ApacheCochiseCoconinoGilaGrahamGreenleeLa PazMaricopaMohaveNavajoPimaPinalSanta CruzYavapaiYuma
How can the Be Connected team help you/your loved ones (check all that may apply):

Vaccine appointmentTransportationFoodHousingEmploymentBenefitsOther
Please share any additional information with the team:
Thank you!

The Be Connected team will follow up on submitted forms within 3 business days or less. When the team contacts you, they will help connect you and your family to resources for your situation. For any additional information, support or any questions, please contact the Be Connected support line at 1-866-4AZ-VETS (429-8387).
Should be Empty:

The Be Connected program is here to help.