BYTC Yuma

NCHP "Best is Yet to Come" Eligibility Screening

The Best Is Yet to Come is a Veteran and Active Duty Suicide Prevention program. Eligibility for this program is based on multiple factors. This is a preregistration form to check for basic qualifications, but does not guarantee entry into program. Referrals will be made for individuals who do not meet our qualifications.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever served in U.S. Armed Forces?*

YesNoNo, but my parent/spouse/family member has.
If yes, about what date did your service begin?

MonthDayYear
Date
If yes, about what date did your service end?

MonthDayYear
Date
If yes, which option most closely represents your discharge status?*

HonorableMedicalGeneralOther than honorableDishonorableDid not serve
Family members of Service Members may qualify for our program. If you are not a service member, but your family member is either Active Duty or a Veteran please indicate below how they are related to you:*

ParentSpouseSiblingChildOtherI am the service member
Do you live with the person referenced above? (If self, select Yes)*

YesNo
Many factors are considered when deciding on if a person meets the qualification requirements. Please select any and all options below that might apply to you:*

Mental Health ChallengesSubstance Abuse ChallengesSerious Chronic Health ConditionsChronic PainTraumatic Brain InjuryProlonged StressStressful Life EventsUnemploymentHomelessnessRecent LossLegal ChallengesFinancial ChallengesPrevious Suicide AttemptsFamily History of SuicideHistory of Abuse, Neglect and/or TraumaNone
How did you hear about our program? Select all that apply.*

TV CommercialRadio CommercialFlyer/AdvertisementFriend/FamilySocial MediaGoogle/Search EngineOther, please specify below
If other, please specify:
Is there anything you wish our Case Managers to know before we contact you? Please share below. *
Should be Empty:

NCHP "Best is Yet to Come" Eligibility Screening