Referral Form 1Crime Information2Contact Information3Miscellaneous Information CommentsThis field is for validation purposes and should be left unchanged.Victim's Name* First Last Victim's Age*Victim's Gender*Select One ...MaleFemaleNon-BinaryDeclined to AnswerOtherPlease Write in Other GenderVictim's Race*Select One ...African American - BlackBiracialCaucasian - WhiteHispanic - Latin AmericanDeclined to AnswerOtherPlease Write in Other RaceDate of Crime* MM slash DD slash YYYY Location of Crime*Select Yes If Crime was Committed in KCKS*NoYesDoes the Victim have Insurance*Select One..YesNoWas the Victim Committing a Crime that Caused Their Death ?*Select One ...YesNoHas the crime been ruled a homicide?* Yes No Not Sure Is law enforcement updating you or your family on the homicide?* Yes No Not Sure Have any suspects been identified or arrests made in the homicide?* Yes No Not Sure Name* First Last Your full nameGender*Select One ...MaleFemaleNon-BinaryDeclined to AnswerOtherYour GenderPlease Write in Other GenderRace*Select One ...African American - BlackBiracialCaucasian - WhiteHispanic - Latin AmericanDeclined to AnswerOtherYour RacePlease Write in Other RaceEmail* An email at which we may contact youStreet Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Method of Contact*Please SelectEmailPhone CallText Message/SMSRelationship to Victim*Please Select...ParentSiblingSpouse/Significant OtherFriendOther (please specify)How do you know the victim?Details*Please describe how you know the victim Add a Secondary Contact Name* First Last Your full nameEmail* An email at which we may contact youPhone*A phone number at which we may contact youStreet Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Method of Contact*Please SelectEmailPhone CallText Message/SMSHow would you prefer to be contactedRelationship to Victim*Please Select...ParentSiblingSpouse/Significant OtherFriendOther (please specify)How do you know the victim?Details*Please describe how you know the victim Do you need assistance with the Funeral Service?* Yes No Which funeral home is in charge of the service ?*Are you aware of the Crime Victims Compensation program in your state?* Yes No Would you like to receive information about Crime Victims Compensation?* Yes No Are there any children in the family who are under 17 years old?* Yes No Enter the age and sex of each child. Names are not required.*Request Grief Counseling Services* Adult Grief Counseling Grief Counseling for Children No Assistance Required Check all that are neededDo you live in Jackson County Mo.?* Yes No Request Additional Services* Rent or House Payment Utilities Food Employment Relocation No Assistance Required Check all that are neededYour Date of Birth* MM slash DD slash YYYY Annual Household Income* $0 to $10,000 $10,001 to $20,000 $20,001 to $30,000 $30,001 to $40,000 $40,001 to $50,000 $50,001 to $60,000 $60,001 to $70,000 Over $70,000 Refused to Answer How many people live in the household?*Is there anything else you want us to know ?* Yes No Additional Comments*How did you come to know about us?* Ad Hoc Group Against Crime Combat Strivin Hub Friend or Relative Funeral Home Media Police or Police Advocate Can we share your info with partner organizations that can offer you services?* Yes No CAPTCHA
