Marcus Alert Voluntary Data Base 

 

Virginia Department of Behavior Health -Link

Marcus Alert HB 
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 the 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 the 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.

Marcus Alert Voluntary Database

Person to be added to database

Address

Emergency Contact Information

Primary Emergency Contact

Alternate Emergency Contact

Health Information

Do you have any of the following medical conditions (check all that apply)

If yes, please list your allergies

Other important information

Healthcare provider name

Healthcare provider phone number

Healthcare provider email

Mental health care providers or case workers

Medications

Stressors

Prevention and wellness process or crisis plan

Anything else that would be helpful for a responder to know, in order to assist you?

Individual Completing this Form

If you are completing this form for someone else, please provide the following information

Relation to individual for whom you are filling out this form

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