Thank you for making your request using this Los Angeles County Veteran Peer Access Network (VPAN) form. Your request is important to us. Someone from our team will respond to your request within 24 -48 business hours. Please be aware that The Veteran Peer Access Network is not a Mental Health treatment program, but rather assists veterans and military family members connect to supportive services, such as peer support, non-urgent mental health linkage, housing, etc. If you believe you or someone else is experiencing a medical or behavioral health emergency, please call your doctor or dial 9-1-1 immediately.

If you are interested in getting connected to resources yourself, please fill out the VPAN Assistance Request form. If you are interested in getting someone else connected to resources, please proceed to complete this referral. If the individual you are referring to VPAN is experiencing suicidal thoughts, homicidal thoughts, and or is gravely disabled, please call our Help Line at 800-854-7771 for immediate assistance. Our Help Line can also help you connect to one of our mental health providers throughout L.A. County for appointments.

Additionally, anyone may call the Help Line at 800-854-7771, press option 3 for Veteran and Military Support Line between 9 a.m. to 8 p.m. to either request resources for yourself or for someone else with an agent directly.
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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* 13. Client's VASH Status

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* 14. VASH Case Manager's Contact Information (If Available)

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* 15. Is the Veteran SP flagged by the VA?

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* 16. Does the Veteran require an SP flag?

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