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)? *

Yes No
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. Cancel of
Organization Type (Select all that apply) *

Direct Service Provider Indirect Service Provider Law Enforcement Victim Service Department Government Agency Program Advocacy Organization Faith-Based Organization
Program Inclusion Selection (Select one option) *

VictimConnect Resource Map AND Internal Database Internal Database ONLY
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 Code Phone Number
Additional Phone #

Area Code Phone Number
Hotline #
Public Address

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

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Service Area *

Local (within limits of local jurisdiction) County (within county limits) Multi-County (between multiple counties but not the whole state) Statewide (within state borders) Multi-State (between multiple states but not nationwide) National (available across the U.S. and territories, including tribal lands)
Does the organization/program operate a hotline? *

Yes No
If yes, what signal types can be used to access hotline services? (Select all that apply) *

Calls Text Messages/SMS Web Chat Email Not Applicable
Hours of Operation *

Program Open 24 hours/day Program Not Open 24 hours/day
If your program is open 24 hours/day, please input a 24-hour range (e.g. 12:00 AM Until 12:00 AM). *

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option
Does the organization have and maintain a policy to protect the identity and information of the victims they serve? *

Yes No
Crime Types (Select all that apply) *

All Crime Types Arson Assault Bullying Child Exposed to Violence Child Physical Abuse or Neglect (Current or Recent) Child Physical Abuse or Neglect (Historical) Child Sexual Abuse Images Child Sexual Abuse (Current or Recent) Child Sexual Abuse (Historical) Cyber Crimes Domestic Violence (Intimate Partner) Domestic Violence (Non-Intimate Partner) Driving Under the Influence Elder Abuse or Neglect Financial Crimes/Fraud/Identity Theft Gang Violence Hate Crime Harassment Homicide Human Trafficking (Labor) Human Trafficking (Sex) Kidnapping (Custodial/Familial) Kidnapping (Non-Custodial) Non-Consensual Pornography Robbery/Theft/Burglary Sexual Assault Stalking Teen Dating Violence Terrorism and Mass Violence Violation of a Court (Protective) Order Other
Services Provided (Select all that apply) *

Batterer Education/Batterer Intervention Case Management/Advocacy Children/Youth/Family Services Counseling/Mental Health/Emotional Support Crime Reporting Crisis Intervention/Crisis Response Domestic Violence Urgent/Acute Response Employment/Education Assistance Financial or Material Assistance Forensic Services General Social Services Hotline/Information and Referrals Housing Emergency/Short-Term Housing (Long-Term/Transitional) Identity Theft Recovery Legal/Justice System Assistance (Civil) Legal/Justice System Assistance (Criminal) Medical/Health Assistance Safety Planning Sexual Assault/Rape Urgent/Acute Response Support Groups Traditional Healing and Referrals Transportation Assistance (Local) Transportation Assistance (Relocation) Victim Rights Advocacy (Non-direct) Other
Fees/Cost of Services (Select all that apply) *

Free Sliding Scale Set Program/Session/Case Fee Accepts Insurance
Service Access Method(s) (Select all that apply) *

Call Web Chat Email Text Message/SMS Walk-in Web Form
Does your organization/program have an intake process? *

Yes No
If Yes, please describe your intake process below. *
Ages Groups Served (Select all that apply) *

Minors (Under 18) Adults
Parent/Guardian Consent Required for Minors? *

Yes No
Genders Served (Select all that apply) *

Female Male Transgender Male Transgender Female Gender Non-binary Gender Non-conforming All Gender Identities
Specialized Programming/Services (Select all that apply) *

Veterans/Military Elders (60+) LGBTQIA+/Two-Spirit Persons Deaf/Hard of Hearing Persons with Disabilities Immigrants/Migrants People without Housing Campus No specialized programming/services Other
If you selected other, please write a short sentence about your specialized programming/services.
Staff Language Skills (Select all that apply) *

English Spanish American Sign Language Other
If you selected other, please write in the language(s).
Do you have access to interpretation services? *

Yes No
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 Code Phone Number
Primary Contact Email *
example@example.com
Secondary Contact First Name
Secondary Contact Last Name
Secondary Contact Phone

Area Code Phone 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

City State / 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.
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