{"id":1556,"date":"2023-02-08T21:09:52","date_gmt":"2023-02-08T21:09:52","guid":{"rendered":"https:\/\/www.vdh.virginia.gov\/central-virginia\/?page_id=1556"},"modified":"2026-04-02T13:11:24","modified_gmt":"2026-04-02T13:11:24","slug":"assistance-request-form","status":"publish","type":"page","link":"https:\/\/www.vdh.virginia.gov\/central-virginia\/assistance-request-form\/","title":{"rendered":"Assistance Request Form"},"content":{"rendered":"<div id=\"pl-1556\"  class=\"panel-layout\" ><div id=\"pg-1556-0\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-1556-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-1556-0-0-0\" class=\"so-panel widget widget_sow-button panel-first-child\" data-index=\"0\" ><div class=\"so-rounded panel-widget-style panel-widget-style-for-1556-0-0-0\" id=\"outreach-button\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-button so-widget-sow-button-flat-73e20f7adabc-1556\"\n\t\t\t\n\t\t><div class=\"ow-button-base ow-button-align-center\"\n>\n\t\t\t<a\n\t\t\t\t\thref=\"https:\/\/redcap.vdh.virginia.gov\/redcap\/surveys\/?s=KXXXYERLLYHPPTAR\"\n\t\t\t\t\tclass=\"sowb-button ow-icon-placement-left ow-button-hover\" \t>\n\t\t<span>\n\t\t\t<span class=\"sow-icon-fontawesome sow-far\" data-sow-icon=\"&#xf086;\"\n\t\tstyle=\"color: #ffffff\" \n\t\taria-hidden=\"true\"><\/span>\n\t\t\tCentral Virginia Health District Assistance Request Form\t\t<\/span>\n\t\t\t<\/a>\n\t<\/div>\n<\/div><\/div><\/div><div id=\"panel-1556-0-0-1\" class=\"so-panel widget widget_sow-editor panel-last-child\" data-index=\"1\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-editor so-widget-sow-editor-base\"\n\t\t\t\n\t\t>\n<div class=\"siteorigin-widget-tinymce textwidget\">\n\t<p style=\"text-align: center;\"><em>Amherst, Appomattox, Bedford, Campbell, &amp; Lynchburg Residents- Submit an Assistance Request Form today!<\/em><\/p>\n<p class=\"cvGsUA direction-ltr align-start para-style-body\" style=\"text-align: center;\"><strong><span class=\"OYPEnA font-feature-liga-off font-feature-clig-off font-feature-calt-off text-decoration-none text-strikethrough-none\">ONE FORM \u2013 ENDLESS CONNECTIONS<\/span><\/strong><\/p>\n<p class=\"cvGsUA direction-ltr align-start para-style-body\" style=\"text-align: center;\"><span class=\"OYPEnA font-feature-liga-off font-feature-clig-off font-feature-calt-off text-decoration-none text-strikethrough-none\">The Central Virginia Health District\u2019s Community Health Workers monitor this referral form daily. All submissions will receive a response within 2 business days.<\/span><\/p>\n<p class=\"cvGsUA direction-ltr align-start para-style-body\" style=\"text-align: center;\"><span class=\"OYPEnA font-feature-liga-off font-feature-clig-off font-feature-calt-off text-decoration-none text-strikethrough-none\">By completing the Assistance Request Form, individuals can be connected to a wide range of services, including:\u00a0<\/span><\/p>\n<p style=\"text-align: center;\">Maternal &amp; Child Health Services, Clinic Services, &amp; more.<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/www.vdh.virginia.gov\/content\/uploads\/sites\/81\/Submitting-an-Assistance-Request-Form.pdf\">Submitting an Assistance Request Form<\/a><\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Amherst, Appomattox, Bedford, Campbell, &amp; Lynchburg Residents- Submit an Assistance Request Form today! ONE FORM \u2013 ENDLESS CONNECTIONS The Central Virginia Health District\u2019s Community Health Workers monitor this referral form daily. All submissions will receive a response within 2 business days. By completing the Assistance Request Form, individuals can be connected to a wide range [&hellip;]<\/p>\n","protected":false},"author":424,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"tags":[],"class_list":["post-1556","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Assistance Request Form - Central Virginia<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.vdh.virginia.gov\/central-virginia\/assistance-request-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Assistance Request Form - Central Virginia\" \/>\n<meta property=\"og:description\" content=\"Amherst, Appomattox, Bedford, Campbell, &amp; Lynchburg Residents- Submit an Assistance Request Form today! ONE FORM \u2013 ENDLESS CONNECTIONS The Central Virginia Health District\u2019s Community Health Workers monitor this referral form daily. All submissions will receive a response within 2 business days. 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