Are you a victim in need of legal assistance?
To schedule an initial consultation, please fill out the form below or call 804-662-0833. Legal Services staff will review completed forms for acceptance and reach out to you via your preferred method of contact within ten (10) business days.
We do not offer crisis services; if you are having an emergency, please call 911. For help with safety planning or other non-legal assistance, call our Victim Assist Helpline at 1-855-4-HELP-VA.
I am completing this form for:
Family or Friend
Are you a resident of Virginia?
Is it okay to call you?
Is it okay to leave you a message?
If your voicemail is full, please add our phone number 804-662-0833 to your contacts so you will know we called.
Is it okay to email you?
What is the best way to reach you?
What time of day do you prefer to be contacted?
Alternate phone or email address
In which city/county and state did the crime occur?
Were there any minor children involved in this incident?
What crime(s) are you the victim of?
Adult Physical Assault
Adult Sexual Assault
Adults Sexually Abused/Assaulted as Children
Bullying (verbal, cyber, physical)
Child Physical Abuse or Neglect
Child Sexual Abuse/Assault
Domestic and/or Family Violence
Elder Abuse or Neglect
Human Trafficking: Labor
Human Trafficking: Sex
Other Vehicular Victimization
Survivors of Homicide Victims
Teen Dating Victimization
If known, please provide the name of the perpetrator.
Are you in danger?
Are you seeking help with a protective order?
Do you have any upcoming hearings or court dates? If so, list the date and location below.
How can we help?
This form is confidential, however, the submission of this form does not establish an attorney-client relationship. It does not guarantee that we will accept your case. VVAN Legal Services staff will review your completed intake and reach out to you regarding scheduling an initial over-the-phone consultation, if appropriate. If you haven’t heard from us within 10 business days, please contact us at 804-662-0833.
I have read and understand the above statement
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This form was created inside of Virginia Victims Assistance Network.