Referral Form 1Crime Information2Contact Information3Miscellaneous Information Victim's Name* First Last Victim's Age* Victim's Sex*Select One ...MaleFemaleVictim's Date of Birth* MM slash DD slash YYYY Location of Crime* Select Yes If Crime was Committed in KCKS*NoYesDate of Crime* MM slash DD slash YYYY Was the Victim Committing a Crime that Caused Their Death ?*Select One ...YesNoDoes the Victim have Insurance*Select One..YesNoAre you or a family member in contact with law enforcement about the status of the homicide?* Yes No Not Sure Are there any suspects or has an arrest been made for the homicide?* Yes No Not Sure Name* First Last Your full nameEmail* 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*Preferred Method of Contact*EmailPhone CallText Message/SMSHow would you prefer to be contacted by us?Relationship 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 youAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*A phone number at which we may contact youPreferred Method of Contact*EmailPhone CallText Message/SMSHow would you prefer to be contacted by us?Relationship to Victim*Please Select...ParentSiblingSpouse/Significant OtherFriendOther (please specify)How do you know the victim?Details* Please describe how you know the victim Is this a request for Funeral Donation* Yes No What funeral home is providing the service ?* Does the victim have children or siblings under the age of 17* Yes No Please give the age and sex of the children*As a result of the homicide do you or any family member need free grief counseling?* Grief Counseling for Adult(s) Grief Counseling for Children None Required at this time As a result of the homicide have you been unable to pay or need assistance with any of the following:* Rent or house payment Utilities Food No assistance is required As a result of the homicide are you in fear of retaliation and need relocation?* Yes No Not Sure Is there anything else you want us to know ?* Yes No Additional Comments*How did you hear about us?* Ad Hoc or Combat Strivin' Hub Friend or Relative Funeral Home Partners For Peace Police/Police Advocate Social Media TV or Radio News Broadcast or Reporter Corey's Network is affiliated with agencies that assist with funeral cost, case management, and advocacy. Do we have your permission to share information with them?* Yes No PhoneThis field is for validation purposes and should be left unchanged.
