top of page

Home
About
UniteVersity
Events
Heal America
More...

Use tab to navigate through the menu items.

Victim Services Intake Form

Disclaimer: Thank you for your interest in the Urban Specialists Help line. This form is used to collect information about new clients and for internal purposes only. The information you provide is confidential and will be treated accordingly. Only with consent will your information be shared

with other partners to provide you with the quick assistance that you deserve during this time.

VICTIM INFORMATION

Victims Name

Date of Birth

Gender

Male

Female

Non-binary

Prefer not to say

Type of Gun Violence Experienced

Gunshot injury

Witnessed gun violence

Loss of loved one due to gun violence

Threatened with a gun

Other

Address*

City*

Zipcode*

Phone

Email (Please be aware that emails may not be confidential) -Is it okay to email you regarding next steps or resource information?*

Preferred method of contact:*

Phone

Email

Text

Other

Emergency Contact Name*

Emergency Contact Phone

Relationship to you*

Address

Legal Custodian / Representative Information

First name

Last name

Date of Birth

Address

Phone

Email

Preferred method of contact:*

Phone

Email

Text

Other

Gender*

Female

Male

Nonbinary

Prefer Not To Say

Relationship Status*

Single

Married

Separated

Prefer Not To Say

Are you head of household?

Yes

No

Number in household

Emergency Contact Name*

Emergency Contact Phone

Relationship to you*

Incident Information

Date of Incident

Time of Incident

:

Brief Description of the Incident:

Did law enforcement respond?

Yes

No

If yes, please provide the report number (if known):

Medical Information

Did you seek medical attention after the incident?

Yes

No

If yes, where were you treated?

Nature of Injuries (Select all that applies):

Physical Injury

Emotional/psychological trauma

Other

Are you currently receiving medical or psychological care?

Yes

No

If yes, please provide details:

Support Needed

What type of support are you seeking from our Victims'; Services?

Emotional/psychological counseling

Legal support

Medical support

Financial assistance

Other

Do you have any immediate needs (shelter, food, etc.)?

Yes

No

If yes, please describe:

Are you currently employed?

Yes

No

Were you employed during the incident?

Yes

No

If yes, did you take bereavement or lose any loss of wages?

Yes

No

Please list your employer and the amount of time you were out from work:

Additional Information

Is there anything else you would like us to know about your experience or the support you need?

Who referred you to the Urban Specialists Victims’ Services?

SmashTopic

Urban Specialist team member

Radio

Flyer/Brochure

Helpline

Friend/Family Member

Other

A Consent for Services

I give my consent to receive services from [Organization Name] Victims Services and understand that my information will be kept confidential.

Yes

No

Signature

Date

Home
About
UniteVersity
Events
Heal America

bottom of page