Please fill out this form to request assistance from VPAN accessing any of these services (housing, training, healthcare, substance abuse intervention, employment, legal advice, education, benefits). You may also contact us directly at veterans@dmh.lacounty.gov or (800) 854-7771, extension 3.
Veteran/Military Family Member's Information

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* 1. First Name

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* 2. Last Name

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* 3. Gender

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* 4. Phone Number

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* 5. Email Address

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* 6. Date of Birth

Date

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* 7. Emergency Contact

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* 8. Mailing Address

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* 9. If you are experiencing homelessness, please provide current location (Exact Address or Nearest Intersection / Cross Streets)

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* 10. What type(s) of assistance is needed?

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* 11. How did you hear about us?

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* 12. Is this referral for yourself or someone else?

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