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2. 
4. Notice: This is not monitored 24/7. If you are in immediate danger, please contact 911 immediately.
6. Whether it is inside or out of your home, we know seeking assistance can be difficult. If you or someone you know is in need of help or just has questions, please reach out below and an advocate will contact you via phone or email and respond to your question to the best of their abilities.
   
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8. Tip: For instructions on how to delete browser history click below:
   How to delete browser history.
12. 1) I have a questions about:*

    1. Sexual Assault
    2. Family Abuse/Violence
    3. Sexual Harrassment
    4. Emotional abuse
    5. Uncomfortable Interactions
    6. Other:
13. If you answered "Other" above, please list the topic here:
15. 2) The item above involves

    1. Me
    2. Someone I know
    3. My Child
    4. Me and my child
    5. Prefer not to answer
17. 3) Please describe your question below.*
19. 4) Are you interested any of the following resources?

    1. Financial Assistance
    2. Rent Assistance/relocation (related to Family Violence or Sexual Assault)
    3. Free Counseling
    4. Job assistance
    5. Application for the Crime Victims Compensation program
    6. Immigration benefits for crime victims
    7. Other:

    Check all that apply
20. Other:
22. 5) How would you like us to respond to your question?*

    1. Phone
    2. Email
    3. Mail
    4. Facebook Post
24. CONTACT INFORMATION
    If you'd like to be contacted by phone or email please enter your contact information below. You are not required to provide both phone and email.
26. 6) Name or Alias:
28. 7) Phone Number:
29. 8) Preferred Call Time:

    1. Morning (9:00 am to 12:00 pm)
    2. Afternoon (12:00 pm to 3:00 pm)
    3. Evening (3:00 pm to 5:00 pm)
    4. Other:

    We can not guarantee your call time, but we will try our best to accommodate.

30. Other:
32. 9) In order to ensure your safety when we call, please include a caution greeting. If we contact you and you respond with this caution greeting we will assume you are not in a secure place to call and will reach back out at a later time. (Optional)
34. 10) Is it ok to leave a message if you do not answer?

    1. Yes
    2. No
37. Email:
39. Thank you for your inquiry, you are always welcome to call victim assistance directly at 972-292-6262
41. Please remember to call 911 if you need immediate assistance
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

* indicates a required field