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Referral for Advocacy Assistance
If urgent assistance is required, please call the Advocate Hotline: 575-303-7072
* Indicates required question
Date of Crime
*
MM
/
DD
/
YYYY
Location of Incident
Your answer
Referring Officer Name
*
Your answer
Referring Agency
*
Your answer
Report Number
*
Your answer
Crime Type
*
Domestic Violence
Sexual Assault
Other
Reason for referral/description of crime
*
Your answer
What services can we assist with?
Counseling
Crime Victim's Reparation
Protection Order
Immigration Assistance Referral
Local Resource Referrals
Medical Exam
Advocate Support Services
Was there strangulation involved in the current or previous incidents?
*
Yes, current
No
Yes, previously
Was the victim treated at the hospital?
*
Yes
No
Unknown
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