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Who is a Victim?
Assistance
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Contact

Home
Who is a Victim?
Assistance
No Cost
Resources
Contact

FREE CALL 24/7

1800 500 058

Contact Form

Please complete the intake form below. All information is kept strictly confidential.

Personal Details

Name *

Address

Phone *

Email *

Date of birth

Are you Aboriginal or Torres Strait Islander?

Yes No

The Incident

What was the date of the act of violence?

Briefly describe the crime

Where did the crime occur? (Suburb)

Did the incident happen on the road as a result of a motor vehicle collision or at your workplace?

Police Report

Has the crime been reported to police?

Yes No

What is the name of the police officer?

Which police station was the crime reported to?

If known, what is the name of the offender?

Injuries

How are you injured?

Physical Psychological Both

Upload a photo of your injury (if physical)

Describe your injury

Counselling & Medical Expenses

Have you paid for past Counselling or Medical expenses?

Yes No

Upload supporting document

Do you need future Counselling or Medical expenses paid for?

Yes No

Safety & Security Expenses

Do you need past Safety / Security expenses paid for?

Yes No

Upload supporting document

Do you need future Safety / Security expenses paid for?

Yes No

Please describe

Loss of Income & Property

Did you lose income because you were unfit to work due to your injuries?

Yes No

Do you need replacement of your clothing that was damaged or lost as a result of the violence?

Yes No

Please list items and value

I confirm the information provided is true and correct to the best of my knowledge. *

No Cost, Immediate, Efficient &
Professional Service to Crime
Victims in Victoria

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Home
Who is a Victim?
Assistance
No Cost
Resources
Contact

Contact Info

Ground Floor 470 St Kilda Road Melbourne
info@crimevictims.com.au
1800 500 058

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