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.

Case ID #

Call received by

Alejandra

Assante

Tileyah

Other

Date and time of Incident

Month

Day

Year

Time

HoursMinutes

Zip code of incident

Service Type

Resource

Victim Services Helpline

Victim Services POC

Google Doc Helpline Form (Self-serve)

Victim's First and Last Name

Is the victim deceased?

Yes

No

Representative's Information

First name

Last name

Email

Address

Zipcode

Phone

What is your relationship to the victim?

Family Status - Are you classified as a female head of household?

1 = Female Head of Household

0 = Other

Number of youth that live in the home.

Number of adults that live in the 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)

Notes

In order to meet program eligibility criteria, the crime must have taken place within the City of Dallas, and they must be a resident of the City of Dallas. Please send the link for the client to upload their documents: https://forms.gle/dYMJqZrMqCk8GdBr7

Do we have your permission to send you emails and or text message notifications?

Yes

No

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