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Name/Pseudonym(Required)

First Last

Preferred Method of Contact(Required)

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Phone

North Carolina County / Out of State

I am inquiring about:(Required)

Your Message

Criminal Victimizations

Demographics

Collecting demographic information helps us (and our funders) to better understand what groups in the community we are and are not serving so that we can improve our outreach, but it is always optional. You do not need to answer these questions to receive our services, but we do appreciate any information you are willing to provide.

Date of Birth

Ethnicity

Gender Identity

Does the person requesting services identify with any of the following (please check all that apply)?¿La persona que solicita servicios se identifica con alguno de los siguientes (marque todo lo que corresponda)?

Deaf or Hard of Hearing / Sordo o dificultades auditivas

Homeless (Includes those residing in shelters or in other temporary housing such as a friend's couch) /Personas sin hogar (incluye a los que residen en refugios o en otras viviendas temporales, como el sofá de un amigo)

Immigrant / Inmigrante

LGBTQIA+

Veteran / Veterano

Person with Disabilities: Cognitive or Physical / Persona con discapacidades: Cognitivo o Físico

Limited English Proficiency / Dominio limitado de la idioma inglés

None of the above or prefer not to answer / Ninguna de las anteriores o prefiero no contestar

Contact Us

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Demographics

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