VS Referral For Services
Please complete this confidential referral for services below.  This form will be sent directly to our Supervisors and someone will contact the client within 3 business days.  If there is an emergent need or a crisis, please call the hotline at 814.288.4961.
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Email *
County *
Person making referral *
Agency
Agency Contact Number *
CLIENT INFORMATION
Client Name *
Date of Birth *
Gender
Clear selection
Parent/Guardian Name (if applicable)
Phone number *
Zip Code *
Please ensure all phone numbers given are safe for us to call
* Safety is a top priority at Victim Services, Inc. Please ensure all phone numbers given are safe for us to call (the offender does not share or monitor the victim's phone, etc.)
Okay to leave a message/say we're calling from Victim Services? *
Reason for Referral/background *
Urgent need (if appropriate) *
Referral for *
Suggested staff member
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