Mobile Crisis Response Intake

Mobile Crisis Response Intake

For individuals (ages 5+) in or near a mental health crisis in Virginia. Please complete this form to help us respond quickly and safely.
Full Name of Person in Crisis

First NameLast Name
Date of Birth (must be 5 years or older)

MonthDayYear
Date
Preferred Name (if different)
Phone Number (if available)
Please enter a valid phone number.Format: (000) 000-0000.
Best Contact Method

Other
Email Address
example@example.com
Current Location (address or cross streets for response)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Relationship to Person in Crisis
Brief Description of Crisis Situation
Is there immediate risk of harm to self or others?
Are weapons, drugs, or aggressive behavior present?
Are there any medical concerns or special needs?
Preferred Language
Is the individual currently receiving mental health or behavioral health services?
If yes, please provide provider/agency name (if known)
Who else is present at the location?
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about The Light Community Crisis Response?
Should be Empty: