BYTC Eligibility Screening

The Best is Yet to Come

Eligibility Screening

NCHP "Best is Yet to Come"

The Best Is Yet to Come is a Veteran and Active Duty Suicide Prevention program. Eligibility for this program is based on multiple factors. This is a preregistration form to check for basic qualifications, but does not guarantee entry into program. Referrals will be made for individuals who do not meet our qualifications. Please fill this out if you are interested in being enrolled in our program and having one of our Case Managers contact you.

Name*

First NameLast Name

Email*
example@example.com

Phone Number*
Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you ever served in U.S. Armed Forces?*

YesNoNo, but my parent/spouse/family member has.

If yes, about what date did your service begin?

MonthDayYear
Date

If yes, about what date did your service end?

MonthDayYear
Date

If yes, which option most closely represents your discharge status?*

HonorableMedicalGeneralOther than honorableDishonorableDid not serve

Family members of Service Members may qualify for our program. If you are not a service member, but your family member is either Active Duty or a Veteran please indicate below how they are related to you:*

ParentSpouseSiblingChildOtherI am the service member

Do you live with the person referenced above? (If self, select Yes)*

YesNo

Many factors are considered when deciding on if a person meets the qualification requirements. Please select any and all options below that might apply to you:*

Mental Health ChallengesSubstance Abuse ChallengesSerious Chronic Health ConditionsChronic PainTraumatic Brain InjuryProlonged StressStressful Life EventsUnemploymentHomelessnessRecent LossLegal ChallengesFinancial ChallengesPrevious Suicide AttemptsFamily History of SuicideHistory of Abuse, Neglect and/or TraumaNone

How did you hear about our program? Select all that apply.*

TV CommercialRadio CommercialFlyer/AdvertisementFriend/FamilySocial MediaGoogle/Search EngineOther, please specify below

If other, please specify:

Is there anything you wish our Case Managers to know before we contact you? Please share below. *

Should be Empty:

Should be Empty:

National Community Health Partners
P.O. Box 1910
Sahuarita, AZ 85629
Main: (520) 795-9756
Fax: (520) 887-0432
E-mail: info@nchponline.org