VictimConnect Resource Inclusion Form

VictimConnect Resource Inclusion Form

Instructions:

To learn more about the program inclusion requirements, read the eligibility criteria here.
If you have multiple programs that you want to be considered for inclusion, please submit one form per each program.
Complete and return all forms to: hotlineleadership@victimsofcrime.org or submit online.
If you have any questions or issues submitting your form online, please contact us at hotlineleadership@victimsofcrime.org.

Basic Information

Organization Name

Please provide the name of the organization that this submission applies to: e.g National Center for Victims of Crime.

Program Name (if applicable)

Please enter the program name that applies to this submission, if appropriate: e.g VictimConnect Resource Center.

Program Description (if applicable)

Please provide a description of your program. If not applicable, please provide a description of your organization.

Program Eligibility

Program Eligibility Confirmation

Please provide information for one of the following (This information will not be shared publicly):

Does your organization/program receive government funding (local, state, federal)?

If yes, please list one of your government funding agencies.

If your organization/program belongs to a regional task force, multidisciplinary team, or etc., please provide a link to a website that lists your organization as an active member or submit a letter of support from your group.

Browse Files

If you are submitting a letter of support, please upload it here.

Organization Type (Select all that apply)

Program Inclusion Selection (Select one option)

If you select Internal Database ONLY, visitors to the VictimConnect Resource Center will only be able to access your public information by communicating with a Victim Assistance Specialist via our helpline.

If you select to be included on our VictimConnect Resource Map, some of the public information you provide about your organization/program will be placed on our website; such as your program name and description, contact information, website link, service area/location, and services provided.

Public Program Information

Public Contact Information

Please do not provide any confidential information.

Website

Fax

Email

example@example.com

Phone #

Area CodePhone Number

Additional Phone #

Area CodePhone Number

Hotline #

Public Address

Please do not provide any confidential information. City and State are required.

Address

Street Address

Street Address Line 2

CityState (Acronym Only)

Zip CodeCountry

Service Area

Does the organization/program operate a hotline?

If yes, what signal types can be used to access hotline services? (Select all that apply)

Hours of Operation

If your program is open 24 hours/day, please input a 24-hour range (e.g. 12:00 AM Until 12:00 AM).

:HourMinutesAM/PM Option

Until

until :HourMinutesAM/PM Option

Does the organization have and maintain a policy to protect the identity and information of the victims they serve?

Crime Types (Select all that apply)

Services Provided (Select all that apply)

Fees/Cost of Services (Select all that apply)

Service Access Method(s) (Select all that apply)

Does your organization/program have an intake process?

If Yes, please describe your intake process below.

Ages Groups Served (Select all that apply)

Parent/Guardian Consent Required for Minors?

Genders Served (Select all that apply)

Specialized Programming/Services (Select all that apply)

If you selected other, please write a short sentence about your specialized programming/services.

Staff Language Skills (Select all that apply)

If you selected other, please write in the language(s).

Do you have access to interpretation services?

Private Program Information

Please list the most appropriate staff member(s) our team should contact for questions about the information submitted on this form. This information will not be publicly shared by our staff.

Primary Contact First Name

Primary Contact Last Name

Primary Contact Phone

Area CodePhone Number

Primary Contact Email

example@example.com

Secondary Contact First Name

Secondary Contact Last Name

Secondary Contact Phone

Area CodePhone Number

Secondary Contact Email

example@example.com

Due to issues with staff turnover, name changes, etc., it is requested that you provide a non-named email address in the event that other emails to your organization bounce and the VictimConnect Resource Center needs to contact your organization. For example, several members of our team check hotlineleadership@victimsofcrime.org.

Backup Organization Contact Email

example@example.com

Private Address

This information will not be shared publicly.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Additional Information

Please use this space to add any additional information the organization would like our staff to know. This could include any of the following information:

The best way to make referrals or important intake information or criteria
Relevant hotline details
If you serve multiple counties, and/or states, name those service areas
Information about gender, age, or population restrictions
Services provided to special populations or specific disability accommodations
Additional information about any services provided

Please indicate whether or not you want the information you provide here made public through our hotline services.