Filling out this form means you’re asking to be connected to a service provider in your area who’s able to meet a social or medical need that you or someone in your care may have. Once completed, this form is sent to our dedicated Veteran Peer Access Network team, who will then connect you to the services you need using Unite Us and make sure you feel supported within 2-3 business days. The information you enter is completely confidential and will only be shared in order to connect you to services. If you need immediate assistance, please call us at 1-800-854-7771 *3.
Use this form only to request services for yourself, or a child (under 18 years old) or adult for whom you have legal guardianship. Consent submitted through this form should be signed by the person who would be receiving services, or by their parent or legal guardian only.If you'd like to make a request for services on behalf of someone else, please fill out the following VPAN Referral Form or call 1-800-854-7771 *3. If you are a direct service provider, sign up to send referrals directly to our VPAN team here.
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