Assistance Request Form

Amherst, Appomattox, Bedford, Campbell, & Lynchburg Residents- Submit an Assistance Request Form today!

ONE FORM – ENDLESS CONNECTIONS

The Central Virginia Health District’s 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 of services, including: 

Maternal & Child Health Services, Clinic Services, & more.

How to Submit an Assistance Request Form

 

Last Updated: July 3, 2025