First Name* :

Last Name :

Address :

Your Phone :

Date of Birth :

Your Email*:

Date(s) of incident(s) or best approximation* :

In what city/town and state did the event(s) take place?*

Where did the event(s) occur (for example: school, business, hospital, workplace, home, parking lot)?*

What is the name of the person or entity that owns or operates the location where the event(s) occurred?

Did you know the person who hurt you?

If you did, what was that person’s relationship to you?

Was the incident(s) reported to the police?

Approximately when was it reported?

To which police department was it reported?

If the incident(s) was not reported to the police, did you ever disclose it to anyone at all?

Approximately when?

Is there an ongoing criminal prosecution?

Briefly describe what happened*:

Briefly describe any physical or emotional injuries you sustained. *:

Have you received any treatment or counselling in connection with this incident? *

Approximate date of first treatment?

Approximate date of last treatment?