Referral Form 1Crime Information2Contact Information3Miscellaneous Information 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 - WhiteDeclined 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 - WhiteDeclined 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 or siblings 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 offer the social services you requested?* Yes No CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
