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    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

  • Program Eligibility

  • Program Eligibility Confirmation

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

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  • 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.

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  • Public Address

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

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  • 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.

     

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  • 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.

  • Private Address

    This information will not be shared publicly.

     

  • 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
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