Urban Specialists Victim Services 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

First name

Last name

Email

Phone Number

Address

Are you the victim?

Yes

No

Are you a U.S. Citizen?

Yes

No

Is the victim a resident of the city of Dallas?

Yes

No

Victims Gender

Male

Female

Other

Was the victim harmed due to gun violence?

Yes

No

Is the victim deceased?

Yes

No

Is the victim a minor?

Yes

No

Can the victim represent themselves?

Yes

No

Case ID#

Name of POC Representative

If no, why not?

Incident Information

When did the incident occur?

Incident Police Report #

Location of Incident

Zip Code of the Incident

Victim Authorized Representative Information

Victim Authorized Representative Name

This will be next of kin, if the victim is not "SELF". In this order: wife/husband, kids, parents, siblings, nieces/nephews, grandparnets, aunts/uncles, cousins

Victim Authorized Representative Contact Number

Victim Authorized Representative Email

Victim Authorized Representative Address

Victim Authorized Representative Zip Code

Preferred method of contact:

Phone

Email

Text

Other

Family Status - Are you classified as a Female head of Household?

1 = Female Head of House Other

0 = Other

Number of youth that live in home.

Number of adults that live home.

Financial Status - Would you consider your income?

1 = Extremely Low Income (Up to 30% AMI)

2 = Very Low Income (More than 30 and less than 50% AMI)

3 = Low Income (More than 50 and less than 80% AMI)

Victim Services Request

Care Package - Receiver Name:

Care Package -Delivery Address:

Support Needed

What type of support are you seeking from our Resource Services?

Mental Health

Mentoring

Financial assistance

Other

Have you applied for Texas Crime Victims' Compensation Program?

Yes

No

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

Yes

No

If yes, please describe:

Additional Information

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

A Consent for Services

I give my verbal consent to receive services from Urban Specialists Victims Services and understand that my information will be kept confidential.

Yes

No

Verbal Consent Signature

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Date

Month

Day

Year

Victim Services Intake Form

Urban Specialists Victim Services Form

Victim Information

Incident Information

Victim Authorized Representative Information

Victim Services Request

Support Needed

Additional Information