Online Request for Victim Services CVRCC serves victims of crime who are residents of Shelby County or a visitor whose crime occurred in Shelby County. Please complete the following form in order to request services. PLEASE NOTE THIS IS ONLY A REQUEST FOR SERVICES - A CVRCC advocate or counselor will respond to you within three business days to discuss your options and eligibility. What type of crime are you writing about? * Domestic Violence Robbery Burglary Assault Murder Adult Sexual Assault Child Sexual Assault Child Physical Abuse Elder Abuse DUI Hit and Run Other If you selected "other," please specify: * When did the crime occur? * Year Year20182019202020212022 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Did you file a police report? * Yes No What is the police report number ? * Are you the victim in the case? * Yes No What is the name of Victim ?? * If you answered "No," what is your relationship to the victim? * Parent Spouse Other Family Member Current Relationship Past Relationship Friend Employer / Coworker Other If you selected "other," please specify: * What type of services are you interested in? * Help with a Domestic Violence problem Help with filing an Order of Protection Assistance with rent Assistance with utilities Counseling Help completing the Criminal Injuries Fund application (aka Victims Comp) Help with the aftermath of Homicide Other assistance If you selected "other," please specify: * How did you hear about the Crime Victims & Rape Crisis Center? Please select the referral source: * Memphis Police Dept. Sheriff's Office District Attorney's Office Social Service Agency Hospital Word of Mouth MIFA Other If you selected "other," please specify: * Please Provide Your Information First Name * Last Name * Please provide your phone number: * Is it safe to leave a message at this phone number? * YES NO If it is safe for you to be contacted by email, please provide your email address: "Please click only once to submit your form."
