Participant Intake Form

All client services provided by Parent Villages are free of charge. This form is to get basic information on your needs and the services you are looking for. This form must first be completed in order to begin our intake process. We would like to collect as much information as possible, but if you are uncomfortable answering any questions, or if the questions do not pertain to you, you can skip them. After the form is submitted you will hear back from Parent Villages within 2 business days. We may need to contact you for additional information as we continue the process. 

 

Parent Villages does not discriminate on the basis of race, color, national
origin, religion, sex, gender identity, sexual orientation, disability, or age.

 

 

 

 

 

 

Violent crime impacts every aspect of a person’s life. The resulting physical and psychological injuries can affect a person’s ability to work, go to school, and meet their own individual goals and aspirations.

Often victims may require treatment to address the injuries caused by the violent acts of another. The monetary expenses incurred – after losing a loved one, for medical and dental care, for psychological assistance, and by injuries resulting in a disability to work – should not serve to further victimize those who are affected by violent crime. 

 

Are you in need of financial assistance for any of the following, or have you had to pay for any of these services due to being a victim or a family member of a victim of crime in Massachusetts within the last three years?

 

 o Lost wages (for victim only)

 o Loss of financial support (for dependents of homicide victims)

 o Funeral/burial

 o Crime scene cleanup* 

 o Forensic Sexual Assault Exam associated expenses*

 o Medical services* 

 o Medical supplies/pharmacy*

 o Dental services* 

 o Replacement homemaker services*

 o Ancillary funeral/burial expenses*

 o Replacement bedding/clothing* 

 o Counseling for victim*

 o Counseling for family members of homicide victims*

 o Counseling for children who witness violence against a family member* 

 o Security Measures* 

 o Counseling for non-offending parents of a child victim

 

 

Have any of these types of crimes affected you? If so, start your application today.

https://www.mass.gov/massachusetts-victims-of-violent-crime-compensation

Someone from Parent Villages is available if you need assistance with your application.

Please note that those affected by violence in anyway would be first priority.