RRCS Voluntary Database

The information you enter into this form will be added to the Rappahannock-Rapidan Community Services (RRCS) Voluntary Database. The database is a requirement of a new law that was signed by the Governor of Virginia in November 2020—The Marcus-David-Peters Act. This database is a partnership between the RRCS, the Department of Behavioral Health and Developmental Services (DBHDS) and local law enforcement. The information that is voluntarily provided on this form will be shared with law enforcement and first-response agencies (police, fire, emergency services) in Rappahannock, Orange, Culpeper, Madison, and Fauquier counties to help ensure an appropriate emergency and/or crisis response. The information you provide will not be used for any other purpose, except to contact you to clarify data entered on this form if needed.

Who are you?

If you are 18 or over, you may enter your own information into RRCS Voluntary Database. Parents or legal guardians of individuals may enter them into the RRCS Voluntary Database; the individual in the database will be removed on their 18th birthday, and may then enroll on their own if so desired.

Are you entering this data for yourself, or someone for whom you are a parent or legal guardian? *

Parent or legal guardian

You have indicated that you are entering data for an individual you are legally responsible for. Please let us know who you are.

If you are entering yourself into the RRCS Voluntary Database, and arrived here by mistake, please go back and select 'Myself' in the previous section.

It is important that we are able to contact you if we need to clarify information on this form, but we understand that some may not have the contact information we have requested. If you do not have a fixed address, an ID card, or a phone number, please enter 'none' in the appropriate fields.

Parent / guardian's first name: *

Parent / guardian's last name: *

Parent / guardian's middle name, additional legal names, or suffixes:

Parent / guardian's preferred name:

Parent / guardian's date of birth: *

Parent / guardian's home street address: *

Parent / guardian's home city: *

Parent / guardian's home state: *

Parent / guardian's home ZIP code: *

Parent / guardian's county of residence: *

Culpeper County, Virginia
Fauquier County, Virginia
Madison County, Virginia

Orange County, Virginia
Rappahannock County, Virginia
Other

Parent / guardian's phone: *

Parent / guardians ID or Drivers License number for verification: *

Parent / Legal Guardian Information	Individual Identification Information	Useful Information	Emergency Contacts	Voluntary Consent

Individual Identification Information

This information will be used to identify the individual in an emergency situation.

Legal first name: *

Legal last name: *

Middle name, additional legal names, or suffixes:

Preferred name:

Date of birth: *

Home street address: *

Home city: *

Home state: *

Home zip code: *

County of residence: *

Culpeper County, Virginia
Fauquier County, Virginia
Madison County, Virginia

Orange County, Virginia
Rappahannock County, Virginia
Other

Enter your phone number:*

ID or Drivers License number for emergency identification purposes: *

Parent / Legal Guardian Information	Individual Identification Information	Useful Information	Emergency Contacts	Voluntary Consent

Useful information

Please describe any information that would be helpful for a multi-disciplinary care team (peer recovery specialist, counselor, fire, rescue, police, etc.) to ensure an appropriate and timely emergency and/or crisis response.

* At least one field in this section must be completed.

What is the best way to approach you in a crisis or emergency? How might you look or act in a crisis or emergency situation?
What approaches or solutions might calm you or make the situation better?

What actions should we attempt to avoid during a crisis or emergency situation? Are there any triggers that should be avoided?

Are you prescribed any medications that may be needed in a crisis or emergency situation?

Is there anything else that would be helpful for first responders to know when first encountering you in a crisis or emergency situation?

Parent / Legal Guardian Information	Individual Identification Information	Useful Information	Emergency Contacts	Voluntary Consent

Emergency Contacts

Please provide at least two emergency contacts (Family member, friend, case manager, probation officer, peer recovery specialist, primary care physician, etc.):

First Emergency Contact

Full name of first emergency contact: *

Relationship with first emergency contact: *

Phone number of first emergency contact: *

Second Emergency Contact

Full name of second emergency contact:

Relationship with second emergency contact:

Phone number of second emergency contact:

Third Emergency Contact

Full name of third emergency contact:

Relationship with third emergency contact:

Phone number of third emergency contact:

Parent / Legal Guardian Information	Individual Identification Information	Useful Information	Emergency Contacts	Voluntary Consent

VOLUNTARY DATABASE

Make a Submission