SCVAN Online Intake Form
We are eager to assist crime victims with their legal issues! In order to best help you, we need to know how to contact you and some brief information regarding the crime you suffered. You will be contacted within 2 business days after submitting an online request. A (*) indicates a required response.
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E-Mail-Adresse *
Name (First and Last) *
Mailing Address (That Is SAFE to Receive Mail, include City, State, and Zip code) *
COUNTY of Residence *
Phone (Please indicate if the number is a home, mobile, or work number) *
What are safe ways for you to be in contact with us? Select all that apply. *
Pflichtfrage
If we are permitted to contact you by phone, what are the best times to call? *
Can we leave you a voice mail? *
Are you a victim of a violent crime? *
If yes, what crime(s) do you believe that you are a victim of? Select from below to the best of your ability. You may select more than one response. *
Pflichtfrage
What assistance do you hope to receive from us? Answer to the best of your ability. You may select more than one response. *
Pflichtfrage
Do you have any immediate concerns for you or your family’s physical or mental safety? If yes, please elaborate briefly below. *
In what city and county did the incident(s) occur? *
Were there any minor children involved in this incident? *
If you have minor children, please list their ages below.
Do you know who the perpetrator is? If yes, provide their name. (Please list N/A if unknown) *
Perpetrator's Address (if unknown, please list N/A) *
Are you a party to a lawsuit or any family court proceedings? If yes, list the date, time, and location of any upcoming proceedings or court hearings. *
Do you have any upcoming meetings with law enforcement, a solicitor, probation or parole, or immigration officials? If yes, list date, time, and location. *
Do you have any pending criminal charges or past criminal convictions?
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Have you ever been arrested before?
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Have you ever been evicted?
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How did you find out about our services? *
Are there any non-legal services you think you might need assistance with? Examples would be referrals for a doctor, therapist, housing, etc.
The submission of this form does not establish an attorney-client relationship and does not guarantee that we will be able to accept your case for representation. *
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