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Wraparound Services
Intake form for services to benefit those impacted by gun violence or Chicago's current crises.
Name
*
First Name
Last Name
How did you hear about R CITY or our services?
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best way to contact you?
Email
Text
Phone call
Other
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Demographic Information
Funding for victims of gun violence is provided through the Cook County Justice Advisory Council which collects anonymous information for the following demographics. Many questions are required, but some are optional or include the response "Prefer not to answer." Please share as you are comfortable. All information is kept private.
Birthdate
*
-
Month
-
Day
Year
Date Picker Icon
Race
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
Other
Ethnicity
*
Hispanic or Latino
Middle Eastern or North African
Not Hispanic/Latino or Middle Eastern/North African
Prefer not to answer
Other
Gender
*
Man
Woman
Transgender woman/transfeminine
Transgender man/transmasculine
Nonbinary/gender nonconforming
Prefer not to answer
Other
Highest Level of Education
*
Please Select
Some High School
High School Graduate/GED
Associate's or Occupational Degree
Partial Bachelor's Degree
Bachelor's Degree
Master's Degree
Professional Degree
Doctoral Degree
Prefer not to answer
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Request for Support
The following questions help us understand your situation, but are not the only determinations of whether you qualify for services. Please answer as you feel comfortable.
At any time, have you or a family member witnessed or experienced gun violence?
*
Yes
No
Have you or your family been affected by Chicago's current events? (Have safety concerns changed your work, school, or home life?)
Yes
No
Other
Can you share with us what happened regarding how you have been impacted by gun violence?
In the last 12 months,
*
I have witnessed gun violence. (or someone in my household)
I have lost a family member to gun violence.
I had a family member survive a gun violence incident.
I have been shot.
None of these.
Other
What services are you interested in?
*
Youth paid apprenticeships
Youth mentoring programs
Clothing, food, or school cost assistance
Housing or utilities cost assistance
Deliveries (groceries, medications, etc.)
Transportation or support person for appointments (doctor, court, etc.)
Funeral/burial costs assistance
Medical or mental health cost assistance or referral
Assistance applying for Crime Victim's Compensation
Assistance applying for public assistance
Other
Anything else you would like us to know about you or your family?
Program
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