Evaluation

1
Applicant Submission Month* This field is required.Please select from the drop-down list below the month you are submitting this application. Previous recipients must wait 12 months before re-applying
Please Select
Please Select
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
2
Date
Date
Year
Month
Day
3
Referral Source* This field is required.
Please Select
Please Select
1. Friend/Relative
2. Alameda County Family Justice Center
3. Report A Victim (Website Form)
4. Heritage Hospital - Sacramento
5. Street Outreach Team ( Foot Canvass)
6. Called Crisis Hotline (+1-866-676-0070)
4
Which Category Best Describes You?* This field is required.Please check all that apply. If non of the above, you are not eligible for this program.
Victim of a Crime
Housed DV Victim- Single Adult
Housed DV Victim- Family
DV Victim Homeless with a Family
DV Victim - Homeless withOUT a Family
Elder Abuse ( Over age of 65)
None of the above
Other
5
Applicant Name* This field is required.
First Name
Last Name
6
Address* This field is required.If homeless , please list Homeless in the fields below.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
County* This field is required.What county are you in?
8
Date of Birth* This field is required.
Date
Month
Day
Year
9
Phone Number* This field is required.
Please enter a valid phone number.
10
Email* This field is required.
example@example.com
11
What is your race/ethnicity?* This field is required.
Please Select
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Caucasian
Multiple Races
12
What languages do you speak?* This field is required.
Please Select
Arabic
Chinese
Deutsch
English
French
Igbo
Japanese
Korean
Mandarin
Russian
Spanish
Swahili
Tagalog
Vietnamese
13
English Proficiency* This field is required.
Please Select
Please Select
Excellent
Good
Fair
Poor
Unable to Judge
14
Education Background* This field is required.
Please Select
Please Select
Graduate School
Bachelors Degree
AA Degree
Some College
High School Diploma
GED or equivalent proficiency
None
15
Date of Incident * This field is required.
Date
Month
Day
Year
16
In five (5) sentences or less, describe your immediate crisis (DV Incident or Crime) and how it affects/affected your overall safety:* This field is required.
17
Was a police report filed? * This field is required.
Please Select
Please Select
Yes
No
18
If Yes, what is the Incident Number and Municipality? (Example: 12345/Oakland PD
19
Have you ever been the victim of domestic violence? (Physical injury committed by a family or household member against another family or household member)** This field is required.
Yes
No
Unsure
Prefere not to answer
20
Have you ever been the victim of human trafficking? (The use of force, fraud, or coercion to obtain some type of labor or commercial sex act from another person)* This field is required.
Yes
No
Unsure
Prefere not to answer
21
Have you ever been the victim of kidnapping? (Forcibly, secretly, or by threat confining, abducting, or imprisoning another person against their will)** This field is required.
Yes
No
Unsure
Prefere not to answer
22
Have you ever been the victim of elder abuse? (Intentional acts by a caregiver that cause significant impairment to an elderly adult's physical, mental, or emotional health)** This field is required.
Yes
No
Unsure
Prefere not to answer
23
Have you ever been the victim of a robbery? (Taking money or property from another person through the use of force, violence, assault, or threat)** This field is required.
Yes
No
Unsure
Prefere not to answer
24
Have you or a family member ever been a victim of or witnessed a homicide? (When one human being causes the death of another, which includes accidents/manslaughter, self-defense, or premeditated murder)** This field is required.
Yes
No
Unsure
Prefere not to answer
25
Have you ever been a victim of a hate crime related to your sexual orientation and/or gender identity or expression? (A crime motivated by bias against or hatred towards someone due to their sexual orientation and/or gender identity)** This field is required.
Yes
No
Unsure
Prefere not to answer
26
Have you ever been a victim of a hate crime targeting any other identity (such as racial, ethnic, or religious identity)?** This field is required.
Yes
No
Unsure
Prefere not to answer
27
Have you ever been denied services due to your race/ gender and/or sexual identity?** This field is required.
Yes
No
Unsure
Prefere not to answer
28
If you were the victim of one or multiple crimes, did you seek out support from any of the following resources? (can select multiple)** This field is required.
Medical professionals
Domestic violence and/or sexual violence survival shelters
VA services
Military family and social services
Hotline
Law Enforcement
Family
Significant other
Friend
Mental health provider
Other victim service provider
Did not use any resources
Have not been a victim of a crime
Prefer not to answer
29
Available Resources* This field is required.
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ORDER SUMMARY
Total costUSD
TIER 1 : Emergency Hotel Voucher Those needing temporary housing can spend up to 7 days in a hotel up to $200 per night for an immediate crisis, at no cost, for Victims of a Crime, Domestic Violence Victims, and the Abused Elderly!
$1,400.00Edit
Back
TIER 1 : Burlington Coat Factory Emergency Clothing Voucher Temporarily housed clients can use this $200 voucher at select Burlington stores for shoes, houseware, clothes and more!
$200.00Edit
Back
TIER 1 : Emergency Visa Gift Card Temporarily housed clients can receive $200.00 Visa gift cards provided at no cost to Victims of Crime, Domestic Violence Victims, and the Abused Elderly!
$200.00Edit
Back
Tier 2 : Emergency Rental Assistance Permanently housed clients and clients who have recently secured housing can sign up to receive a one-time payment of $1,000.00 for expenses related to Leases, Rents, Mortgages or Repair to property (damaged during a crime). Provided to Victims of a Crime, Domestic Violence Victims, and the Abused Elderly!
$1,000.00Edit
Back
TIER 2 : Emergency Amazon Gift CardPermanently housed clients and clients who have recently secured housing can receive a Digital or Physical $300.00 gift cards are provided at no cost to Victims of a Crime, Domestic Violence Victims, and the Abused Elderly!
$300.00Edit
Back
TIER 2 : Emergency Petty CashPermanently housed clients receive up to $200 cash for transportation expenses and other expenditures.
$200.00Edit
Back
Enter Coupon
Total cost $0.00
30
Invoice ID
31
What is your preferred delivery method for the requested items? * This field is required.
United States Postal Service (Expedited 2-Day Delivery)
In-Person
32
I Client Full Name * affirm that within the last 12 months I have been a victim of or suffered the consequences of a qualifying crime in the State of California. I understand that a qualifying crime involves physical injury, emotional injury, financial abuse, threat of physical injury, or death in order to qualify for compensation. Furthermore, I assert, the above-mentioned information is true and correct to the best of my knowledge.
33
Please click the "Submit" button below to send your evaluation to a intervention specialist.
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