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.

If you selected "other," please specify: *

When did the crime occur? *

Year

Month

Day

Did you file a police report? *

Yes

What is the police report number ? *

Are you the victim in the case? *

Yes

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: *

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

If it is safe for you to be contacted by email, please provide your email address:

"Please click only once to submit your form."

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Math question * 9 + 2 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

Translator

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.