Victim Services

VICTIM INFORMATION
Date of Service*
MM slash DD slash YYYY
Was this a group or an individual?*
Was the individual served the actual victim or victim family?
Individual or Group Name
Type of Group
Total # of People Served in the Group or Event
Victim Name
First Last
3. Has this victim received services in the past?*
4A. Race/Ethnicity for NEW Victims
4B. Gender Identify for NEW victims
4b6. If "Other" please describe here:
4C. Age for NEW Victims
5. Type of Victimization*
Check all that apply.
5bb. If "Other" above describe here:
5cc. If "Hate Crime", please describe what type here (Racial/Religious/Gender/Sexual Orientation, etc):
6. Did this victim present with more than one type of victimization (secondary victimization)*
6a. Type of Secondary Victimization
Check all that apply.
7. Special classification of victims
7i. If "Other" above please describe here:
DIRECT SERVICES
What type of service was provided?
How many times did we provide services?
Court proceedings outcome?
Parole hearing outcome?
How many family members attended the press conference?
Description*
Please briefly describe each service/interaction.

VICTIM INFORMATION

DIRECT SERVICES