CVHR Intake

1. CVHR Intake Questionnaire - Instructions and Contact Information

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**PLEASE NOTE: Failure to complete and/or sign the intake could result in the CVHR declining to review your intake.**

IMPORTANT: Please note that it may take up to three weeks to process this intake. If you have an upcoming hearing within that time, you may decide to request a continuance on your own behalf.

Thank you for contacting the Center for Victim and Human Rights (CVHR).

Before we can accept you as a client, we must ask you to complete our intake. The intake allows us to best identify the issues regarding your case and helps us decide whether we can accept your case.

Please consider the following information before you submit your intake:

1.) We do not represent you until the CVHR enters into a written agreement to represent you. Therefore, completing the intake does not represent the formation of an attorney-client relationship.

2.) Answer all of the questions as completely as possible. The more complete your answers, the better we are able to ascertain whether we can help you. Failure to completely answer the questions AND sign your intake may result in our declining to review your case.

3.) If the answer is “none,” please type “none.” If the answer is “not applicable,” please type “N/A.”

4.) If you need help completing the intake, you may seek assistance; however, please include the contact information for the individual who assisted you in the appropriate section of the intake.

5.) The information contained in your intake will remain confidential as per the CVHR confidentiality and privacy policies.

6.) Please do not send any additional documentation unless specifically asked by us.

7.) The CVHR uses the federal poverty guidelines for determining whether a client is determined to be indigent for pro bono representation purposes.

Alternately, you may hand-write the intake and mail it to us:

Center for Victim and Human Rights
ATTN: Intake
201 N. Illinois Street
16th Floor, South Tower
Indianapolis, IN 46204

If we believe we can assist you, we will contact you.

If you have questions, please feel free to contact us via e-mail at Contact@cvhr.org or via phone at (317) 610-3427. Please allow at least three business days for us to return your e-mail or call.

Thank you for respecting our policies in working with us and for the opportunity to work with you.

**PLEASE NOTE: Failure to complete the intake and/or sign the intake could result in the CVHR declining to review your intake.**

The CVHR Team

Question Title

* 1. How did you hear about us?

Internet search (Google, Yahoo, Ask)

Referral

Friend

Family Member

Other

If you select "Referral" or "Other," please list the contact information for that organization or person:

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* 2. Salutation

Mr.

Mrs.

Ms.

Dr.

Other (please specify)

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* 3. First Name

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* 4. Last Name

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* 5. Middle Name

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* 6. Maiden Last Name (please type "None" if no maiden name or "N/A" if not applicable).

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* 7. Other names used (please type "None" if no other names have ever been used):

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* 8. Please provide safe contact information below:

Name: *

Company:

Address: *

Address 2:

City/Town: *

State: *

ZIP/Postal Code: *

Country: *

Email Address:

Phone Number:

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* 9. Please provide secondary safe contact information (if applicable) below:

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Country:

Email Address:

Phone Number: