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)?*

YesNo
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. Cancelof
Organization Type (Select all that apply)*

Direct Service ProviderIndirect Service ProviderLaw Enforcement Victim Service DepartmentGovernment Agency ProgramAdvocacy OrganizationFaith-Based Organization
Program Inclusion Selection (Select one option)*

VictimConnect Resource Map AND Internal DatabaseInternal 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 (Acronym Only)
Zip Code Country
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?*

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

CallsText Messages/SMSWeb ChatEmailNot Applicable
Hours of Operation*

Program Open 24 hours/dayProgram 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?*

YesNo
Crime Types (Select all that apply)*

All Crime TypesArsonAssaultBullyingChild Exposed to ViolenceChild Physical Abuse or Neglect (Current or Recent)Child Physical Abuse or Neglect (Historical)Child Sexual Abuse ImagesChild Sexual Abuse (Current or Recent)Child Sexual Abuse (Historical)Cyber CrimesDomestic Violence (Intimate Partner)Domestic Violence (Non-Intimate Partner)Driving Under the InfluenceElder Abuse or NeglectFinancial Crimes/Fraud/Identity TheftGang ViolenceHate CrimeHarassmentHomicideHuman Trafficking (Labor)Human Trafficking (Sex)Kidnapping (Custodial/Familial)Kidnapping (Non-Custodial)Non-Consensual PornographyRobbery/Theft/BurglarySexual AssaultStalkingTeen Dating ViolenceTerrorism and Mass ViolenceViolation of a Court (Protective) OrderOther
Services Provided (Select all that apply)*

Batterer Education/Batterer InterventionCase Management/AdvocacyChildren/Youth/Family ServicesCounseling/Mental Health/Emotional SupportCrime ReportingCrisis Intervention/Crisis ResponseDomestic Violence Urgent/Acute ResponseEmployment/Education AssistanceFinancial or Material AssistanceForensic ServicesGeneral Social ServicesHotline/Information and ReferralsHousing Emergency/Short-TermHousing (Long-Term/Transitional)Identity Theft RecoveryLegal/Justice System Assistance (Civil)Legal/Justice System Assistance (Criminal)Medical/Health AssistanceSafety PlanningSexual Assault/Rape Urgent/Acute ResponseSupport GroupsTraditional Healing and ReferralsTransportation Assistance (Local)Transportation Assistance (Relocation)Victim Rights Advocacy (Non-direct)Other
Fees/Cost of Services (Select all that apply)*

FreeSliding ScaleSet Program/Session/Case FeeAccepts Insurance
Service Access Method(s) (Select all that apply)*

CallWeb ChatEmailText Message/SMSWalk-inWeb Form
Does your organization/program have an intake process?*

YesNo
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?*

YesNo
Genders Served (Select all that apply)*

FemaleMaleTransgender MaleTransgender FemaleGender Non-binaryGender Non-conformingAll Gender Identities
Specialized Programming/Services (Select all that apply)*

Veterans/MilitaryElders (60+)LGBTQIA+/Two-Spirit PersonsDeaf/Hard of HearingPersons with DisabilitiesImmigrants/MigrantsPeople without HousingCampusNo specialized programming/servicesOther
If you selected other, please write a short sentence about your specialized programming/services.
Staff Language Skills (Select all that apply)*

EnglishSpanishAmerican Sign LanguageOther
If you selected other, please write in the language(s).
Do you have access to interpretation services?*

YesNo
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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