R CITY Victims Services Form

Complete the survey below and a staff member will be in touch with you.

First Name

Last Name

How did you hear about R CITY or our victims services?

Phone Number

Best way to contact you?

EmailTextPhone Call

Address Line 1

Apartment Number?

City

State

Zip Code

Services Survey

Have you or a family member witnessed or experienced violence?

Would you like to share with us what happened? (This is completely optional.)

Anything else you'd like us to know about you?