First Responder Family Support Request Form

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We understand that supporting a first responder comes with unique challenges. If you're a spouse, partner, parent, sibling, or loved one of a first responder and you're looking for support, connection, or information, you're not alone — and we're here to help.

Please fill out the form below, and a member of our team will reach out to you within 2 business days. This form should not be used if you are in a crisis. Please call 988 or 911 if you are experiencing an emergency.

Name *

Phone Number

How would you like us to contact you? *

Phone

Text

What is your relationship to the first responder? *

Spouse or Partner

Parent

SIbling

Adult Child

Friend or extended family

Other:

What kind of support are you seeking? (Please choose all that apply) *

Emotional support or someone to talk to

Information on how to better support my loved one

Peer support from other first responder families

Counseling or mental health resources

Other:

Required

Please share anything you’d like us to know about your situation or how we can best support you:

Would you like to receive occasional updates, resources, or invitations to family support events?

Yes

Clear selection

I understand that Priority Wellness Campaign does not offer emergency crisis care and that the services offered are meant for non-life-threatening mental health crises. I will call 988 or 911 if I'm experiencing an emergency.

I agree

I disagree

Submit

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