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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.

Urban Specialists Victim Services Form

Are you the victim?
Is the victim a resident of the city of Dallas?
Victims Gender
Was the victim harmed due to gun violence?
Is the victim deceased?
Is the victim a minor?
Can the victim represent themselves?
Yes
No

Incident Information

Victim Authorized Representative Information

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

Preferred method of contact:
Family Status - Are you classified as a Female head of Household?
1 = Female Head of House Other
0 = Other
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)
Race and Ethnicity
1 = White
2 = Black/ African American
3 = Asian
4 = American Indian/ Alaskan Native
5 = Hispanic
1A = American Indian/ Alaskan Native & White
2B = Asian & White
3C = Black/ African American & White
4D = American Indian or Alaskan Native & Black & African American
5E = Other Multi-Racial

Approval for Victim Services

Repast Services: Type
Catering
Groceries

Please specify: Online cater's name/ Wal-mart Online order

Emergency Food Approved
Yes
No

Specify: Wal-mart location preferred by the client for pick up orders or another approved grocery store.

Ballon Release Support.
Yes
No

Support Needed

What type of support are you seeking from our Resource Services?
Do you have any immediate needs (shelter, food, etc.)?

Additional Information

Who referred you to the Urban Specialists Victims’ Services?

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.
Is the victim a minor?
Yes
No
Date
Month
Day
Year
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