Anonymous Wellness Check Request Form
Confidentially request a wellness check for someone you are concerned about. Your identity will remain anonymous unless you choose to provide your contact information.
Do you wish to remain anonymous?
*
Yes, I want to remain anonymous
No, I am willing to be contacted if needed
Name of the person you are concerned about (if known)
Approximate age or age group of the person (if known)
Location of the person (address, neighborhood, or general area)
*
What is your relationship to this person?
*
Please Select
Family member
Friend
Neighbor
Colleague
Acquaintance
No relationship / Concerned citizen
Other
Reason for your concern (please describe the situation)
*
When did you last have contact with this person?
*
Please Select
Within the last 24 hours
Within the last week
Within the last month
More than a month ago
Never had contact
How urgent is your concern?
*
Immediate (life-threatening emergency)
High (serious concern, but not immediate danger)
Moderate (general welfare check)
Please provide any additional details that may help responders (e.g., physical description, known health issues, pets, etc.)
If you are willing to be contacted for further information, please provide your email address (optional)
example@example.com
If you are willing to be contacted for further information, please provide your phone number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Request
Should be Empty: