Shelby County Crime Victims & Rape Crisis Center
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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 - Includes Shootings
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
Year
2022
2023
2024
2025
2026
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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."
