Tribal Resource Tool Provider Inclusion Form

Welcome to the Provider Inclusion Form for the Tribal Resource Tool!

Instructions

Organizations/agencies that wish to be included in the Tribal Resource Mapping Tool must complete all fields to be considered for inclusion. Letters of support or referrals from additional agencies may be requested, at the discretion of program staff.

Please note that this form is best completed on a desktop computer rather than a tablet or cell phone.

Information provided to the Tribal Resource Mapping Tool will be shared internally with National Center for Victims of Crime staff as well as the StrongHearts Native Helpline team.

All sections of this form may be publicly visible via the web-based Tribal Resource Mapping Tool.

The following form will ask you several question about your entity/organization and the program/department you represent (if relevant).

Questions with a red asterisk next to them are required fields. Please be aware that as you answer questions, new questions may appear and those may be required as well.

When presented with an open ended text box, please refrain from copying and pasting from your website, using special characters ( !#$^&* ), or referring to answers for other questions. If you choose to do these things, be advised that the processing time for your entry will be significantly delayed, and may require follow-up via email or phone call, and/or form re-submission.

If you have questions or concerns regarding content or your answers to questions, please email the NCVC team at anevaquaya@victimsofcrime.org.
Basic Introductory Entity/Organization Information

Entity/organization refers to an agency that serves as an umbrella organization, such as nonprofit or tribe, for various services or departments. If your organization’s sole purpose is to serve survivors of crime and abuse, then provide information about the organization in the following sections.

Program/Department refers to a particular service or office under a larger entity/organization. This section is most appropriate for programs that are operated by a tribe, or a specific department within an agency. If applicable, provide information about the program/department in the following sections.
Tribe/Entity/ Organization Name*
Please provide the name of the entity or tribe that this submission applies to. e.g. National Center for Victims of Crime e.g. Sault Ste. Marie Tribe of Chippewa Indians
Program/ Department Name (if applicable)
Please enter the program name that applies to this submission, if appropriate. e.g. VictimConnect Hotline
Tribe/Entity/ Organization Mission Statement/ Description*
Please provide a 2-3 sentence mission statement or descriptionof the entity/organization
Program/ Department Mission Statement/ Description (if applicable)
Please provide a 2-3 sentence mission statement or descriptionof the program/department.
Tribe/Entity/ Organization Type*
Entity/Organization Age*

0-5 Years6-10 Years11+ Years
Please indicate an estimate of how many people (crime victims or other) the organization serves each month.*
Does the Tribe/Entity/ Organization or Department/ Program Offer A Hotline?*

YesNo
What Signal Types Can Be Used To Access Hotline Services?*

CallsText Message/SMSWeb ChatEmailTTY/Accessibility
Operational Information
What is your primary operating time-zone?*

EasternCentralMountainPacificAlaskaHawaii
Organization/Entity is open 24 hours/day*

YesNo
Organization/Entity Opening Time *

:HourMinutesAM/PM Option
Organization/Entity Closing Time *

:HourMinutesAM/PM Option
Program/ Department is open 24 hours/day (if applicable)

YesNo
Program/ Department Opening Time *

:HourMinutesAM/PM Option
Program/ Department Closing Time *

:HourMinutesAM/PM Option
Services are Available on Weekends*

YesNo
Public Contact Information

Information Will Be Displayed On the Tribal Resource Tool
Organization/Entity Website*
Public Office Email
Please provide an email address that victims and userswould be able to use to access services. Please onlyprovide an email address if it is regularly checked andusers can expect a response.
Program/ Department Website
Public Office Phone Number*

Area CodePhone Number
If you utilize Facebook as a social media platform, please enter link here.
Public Address

For Public Distribution (via website and/or StrongHearts Native Helpline Referral)
*

Street Address

Street Address Line 2

CityState (Acronym Only)

Zip Code
Private Contact Information

Information Will Be Used Internally By NCVC and StrongHearts Native Helpline

Please list the most appropriate person that the project team would be able to contact for questions about the information submitted on this form.
Primary Contact First Name*
Primary Contact Last Name*
Primary Contact Phone *

Area CodePhone Number
Primary Contact Email*
example@example.com
Backup Organization Contact Email*
Due to issues with staff turnover, name changes, etc., it is requestedthat you provide a non-named email address in the event that otheremails to your organization bounce and NCVC needs to contactyour organization. For example, tribal@victimsofcrime.org ischecked by several members of the NCVC team.
Secondary Contact First Name
Secondary Contact Last Name
Secondary Contact Phone

Area CodePhone Number
Secondary Contact Email
example@example.com
Private Address

For Internal NCVC and StrongHearts Native Helpline Use Only
*

Street Address

Street Address Line 2

CityState

Zip Code
Services and Access
Does the organization have and maintain a policy to protect the identity and information of the victims they serve?*

YesNo
Crime Types

The organizations in the Tribal Resource Mapping Tool will be focused on serving victims of crime. Indicate the types of crime in which the organization is able to assist. (Select all that apply). Only select crime types in which the organization is able to provide specialized programming.

Please click here for a comprehensive list of definitions for the crime types below.
BullyingChild Exposed to ViolenceChild Abuse/Neglect (Active/ Recent)Child Abuse (Past)Child PornographyChild Sexual Abuse (Active or Recent)Child Sexual Abuse (Past)Cyber CrimesDomestic Violence (Intimate Partner)Domestic Violence (Non-Intimate Partner)Drunk or Drugged DrivingElder Abuse/NeglectFraud/Identity TheftGang ViolenceHate CrimeHarassmentHomicideLabor TraffickingSex TraffickingKidnapping (Custodial/Familial/Non-Custodial)Property Crime (Robbery/Theft/Burglary/Arson)Sexual AssaultStalkingViolation of a Court (Protective) Order
Services Offered

Indicate the types of services the organization is able to provide.

*Should an organization wish to provide additional information about any services provided, that information can be added to the “Additional Information” section at the end of this page.

Please click here for a comprehensive list of definitions for the services listed below.
Batterer Education/Batterer InterventionChildren/Youth/Family ServicesCounseling/Mental Health/Emotional SupportDomestic Violence ResponseEmployment/Education AssistanceFinancial AssistanceGeneral Social ServicesHotline/Information and ReferralsHousing Emergency/Short-TermHousing (Long-Term/Transitional)Law EnforcementLegal/Justice System AssistanceMedical/Health AssistanceSafety PlanningSexual Assault/Rape Urgent/Acute ResponseSupport Groups/Talking CirclesTraditional Healing and ReferralsTransportation Assistance (Local)Transportation Assistance (Relocation)Victim Rights Advocacy (Non-direct)
Service Area

Please select the most appropriate service area.

*If you serve multiple counties, states and/or tribes,
name those service areas below in the “Additional Information” section at the end of this page.
*

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)Tribal Nations (only within the limits of designated tribal nation(s))
Fee/Cost of Services

Please select the appropriate type(s) of fee structure.
*

FreeSliding ScaleSet Program/Session/Case FeeAccepts Insurance
Service Access Method(s)

All agencies have policies on the entry of new clients.
Indicate the best way(s) crime victims should access services.
*

CallWeb ChatEmailText Message/SMSWalk-inWeb Form
Ages Served

Please select all age groups the organization/program
may be able to serve.

*Should certain programs with the organization have age restrictions, please indicate that information below in the “Additional Information” section at the end of this page.
*

0-12 Years13-17 Years18-60 Years60+ Years
Genders Served

Please select all genders the organization may be able to serve.

*Should certain programs with the organization have gender restrictions, please indicate that information below in the “Additional Information” section at the end of this page.

Click here for definitions of the genders listed below
*

FemaleMaleTransgenderGender Non-binary
Please indicate the specific populations that your organization/ program serves.*

Everyone including non-AI/AN populationsEnrolled Members of a Federally Recognized Tribe onlyEnrolled Members of a Federally Recognized Tribe and their descendantsAccess to Services Requires a Certificate of Degree of Indian Blood/Degree of Alaska Native Blood
Are descendents required to show proof of descendancy?*

YesNo
Special Programming/Services Available for the Following Populations

Select any groups here that the organization is able to provide specialized services. Specialized services is defined as an agency providing outreach or services that is specific to one of these groups. Please do not choose these groups if the organization is able to provide services to them but do not have dedicated staff or programs focused on these areas.

*Please outline the services provided to these populations below in the “Additional Information” section at the end of this page.

*Add any specific disability accommodations below in the “Additional Information” section at the end of this page.
Veterans/MilitaryElders (60+)LGBT+/Two-Spirit PersonsDeaf/Hard of HearingPersons with Disabilities
Tribal Language Access
Does your entity/organization and/or program have proficiency in at least one tribal language?*

YesNo
Please indicate the tribal languages the entity/organization or program are proficient in:*

ArapahoCherokeeChickasawChoctawCrowDakotaGros VentreHopiLakotaMescaleroMohawkMuscogee CreekNavajoOjibweSalish Ql'ispeShoshoniTohono O'odhamZuni
Non-Tribal Language Access

Please indicate all languages that the organization is able to provide services or translation – this also includes American Sign Language.
Please indicate the non-tribal languages the entity/organization or program are proficient in:*

EnglishSpanishAmerican Sign Language
Tribal Specific Information
Is the Organization/Entity Tribal Affiliated*

YesNo
Is the Organization/Entity Owned/Operated By A Tribe*

YesNo
Does the Organization/Entity Employ AI/AN Staff*

YesNo
Does the Organization/Entity Have AI/AN Board Members*

YesNo
Is the Organization/Entity Affiliated With/A Member of a DV/SA Tribal Coalition*

YesNo
Please Select the DV/SA Tribal Coalition with whom the Organization/Entity is Affiliated

American Indians Against AbuseCoalition to Stop Violence Against Native WomenFirst Nations Women’s AllianceHealing Native Hearts CoalitionHopi-Tewa Women’s Coalition to End AbuseMending the Sacred Hoop Tribal Domestic Violence CoalitionMinnesota Indian Women's Sexual Assault CoalitionMontana Native Women’s CoalitionNative Alliance Against ViolenceNative Women’s Society of the Great PlainsRestoring Ancestral WindsSeven Dancers CoalitionSouthwest Indigenous Women’s CoalitionStrong Hearted Native Women’s CoalitionUniting Three Fires Against ViolenceWabanaki Women’s CoalitionWomenSpirit CoalitionYup’ik Women’s Coalition
Does the Organization/Entity Provide Tribal Specific Programming*

YesNo
Is the Organization/Entity Funded Specifically to Serve AI/AN Victims*

YesNo
Does the Organization/Entity Mission Statement Explicitly Include Serving AI/AN Populations*

YesNo
Does the Organization/Entity Provide Advocates Equipped to Appear in Tribal Courts*

YesNo
Number of AI/AN Victims Served (Last 12 Months)*
What Percentage of People Served by the Organization/Entity are AI/AN*
Please enter as a percentage (%)
Culturally Specific Services
Does the Organization/Entity Offer Culturally Specific Activities*

YesNo
List Culturally Specific Activities Offered, Separated by a Semicolon (;)*
Does the Organization/Entity Offer or Provide Referrals To Traditional Healing Services*

YesNo
Explain the Process for Vetting Traditional Healers/Traditional Healing Services*
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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