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victim Intake form
Advocate/Caller Name
Advocate/Caller Agency
Applicant Name
Opposing Party's Name
How Do You Identify?
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Are There Any Additional Special Circumstances That We Should Be Aware Of?
Are You A Victim Of Crime?
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Brief Summary Of Why You Are Calling
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SAFETY ALERT: If you are in danger, please use a safer computer, call 911, a local hotline, the National Sexual Assault Hotline at 1-800-656-4673 or the U.S. National Domestic Violence Hotline at 1-800-799-7233.
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