VAFCC Telehealth Service Network (VAFCC-TSN) Intake Form
Thank you so much for your dedication to expand much-needed access to care for vulnerable patients. Your assistance comes during a time of great need, when COVID-19 associated lay-offs and policy changes increase the loads placed upon free clinics. If you know of any others who may be a good fit for this type of volunteering, please share this form with them. If you are interested in volunteering as a recruiter for this initiative, please email
in lieu of completing this form.
What is your first name?
What is your last name?
At what email address should we send communications?
What is your preferred contact number? ex. 012-345-6789
Which of the following best describes your intended role of service?
Please resubmit another form if you have an additional applicable service role.
B. Spanish Interpreter
F. Social Worker
H. Nurse Practitioner
K. Physican Assistant
O. Physical Therapist
P. Mental Health Therapist
Z1. Administrative Volunteer
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