Request Service - for myself Filling out this form is not an indication of an attorney/client relationship and does not guarantee legal representation. Please do not include your social security number or other confidential financial information on this form. You are not required to provide this information for our services. Please note: There are some cases we cannot accept. Do you have a disability? yes no What disability or disabilities do you have? First Name Last Name Street or Mailing Address If you live in a facility, please also provide name of facility (if not, please skip question) – City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth DakotaNorth CarolinaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Email Phone number When is a good time for us to contact you about your issue? Do you have any preferences on how you would like us contact you (email/phone call)? Do you have any of the following? Check all that apply. Use the CTRL key to select more than one option. GuardianConservatorDurable Power of AttorneyRepresentative Payee Gender No valueFemaleMaleOtherPrefer not to answer Race No valueAlaskan NativeAmerican IndianAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderTwo or more racesWhitePrefer not to answer Are you Hispanic/Latino? yes no What is your age? Have you ever been the victim of a crime? It is not required that the crime was ever reported to the police. yes no If you have been the victim of a crime, check all that apply below. Use the CTRL key to select more than one option. Adult Physical AssaultAdult Sexual AssaultAdult that was sexually abused/assaulted as a childArsonBullying (verbal, cyber, or physical)BurglaryChild physical abuse or neglectChild PornographyChild Sexual Abuse/AssaultDomestic and/or Family ViolenceDUI/DWI IncidentsElder Abuse or NeglectHate Crime: Racial/Regligious/Gender/Sexual Orientation/OtherHuman Trafficking: LaborHuman Trafficking: SexIdentity Theft/Fraud/Financial CrimeKidnapping (custodial)Kidnapping (non-custodial)Mass Violence (Domestic/International)Other Vehicular Victimization (e.g. Hit and Run)RobberyStalking/HarassmentSurvivors of Homicide VictimsTeen Dating VictimizationTerrorism (Domestic/International)Violation of a Court (Protective) Order Have you received your COVID-19 vaccine? No valueYesNoOne dose of Pfizer/Moderna onlyIneligible for the vaccinePrefer not to answer If you are only partially vaccinated, do you have your second COVID-19 vaccine dose scheduled? No valueYesNoNot applicable - I'm fully vaccinatedNot applicable - ineligible for the vaccinePrefer not to answer If you haven't received your COVID-19 vaccine yet, are you planning to get vaccinated? No valueYesNoNot applicable - I'm already vaccinatedPrefer not to answer What is your reason for contacting the DRC? How would you like DRC to help? What would you like to see happen? Is anyone else helping you with this issue? If so, who?
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