Victims Of Crime Application for Compensation & Counseling

As an applicant to Victims Of Crime Counseling & Compensation Services you are required to detail the crime that occured to you, such that the formal procedures of seeking compensation for the detrimental effects that the crime has had upon yourself, may be undertaken.

This online form is a starting place for that procedure.

The form is comprehensive, however, you need only fill the form as much as your able, or would want to, at this stage.

Be sure to include an accurate email address and phone number.

Applicant Enquiry

1. Your Name(required)
2. Date of Birth(required)
3. Address(required)
4. Email(valid email required)
5. Phone(required)
6. Preffered Time to Call
7. 9am - 11am 11am - 1pm 1pm - 3pm

Incident Details

1. Incident Description
2. Incident Date
3. Police Statement
4. Offenders Details
5. Other Victims
6. Witnesses

Injuries Sustained

1. List Physical Injuries
2. List Psychological Injuries
3. Other health difficulties resulting from the incident
4. Medical & Other Reports

Post Incident Functional Impairments

1. Interpersonal
2. Social
3. Vocational
4. Educational
5. Recreational
6. Other
7. Indicate an overall percentage of impairment
8. 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Treatment Post Incident

1. Physical Treatment
2. Psycological Treatment
3. Other Treatment
4. Describe your Social Support
5. Describe any Future Treatment required
6. List anything else needed to help you recover

Your Health Before The Incident

1. Physical Health
2. Psychiatric Health
3. Medication

Trauma History

1. List other trauma
2. List any other Personal Injury Claims

Family History

1. Describe Your Family History
2. Marriage Status
3. Partner Details
4. Children
5. Parents
6. Siblings

Other History

1. Employment
2. Social
3. Recreational
4. Financial
5. Cultural / Religious
6. Criminal Convictions

Substance History Before & After the Incident

1. Alcohol
2. Drugs
3. Cigarettes
4. Gambling
5. Other

Out Of Pocket Expenses

1. Indicate any of the following expenses:
2. 1. Loss of Income
3. 2. Medical
4. 3. Pharmaceutical
5. 4. Psychiatric / Psycological
6. 5. Physiotherapy / Chiropractic
7. 6. Dental
8. 7. Ambulance
9. 8. Travelling
10. 9. Moving House
11. 10. Damage to Clothing
12. 11. Electricity / Telephone
13. 12. Other ( such as Changed House Locks & Improved Home Security )
14. List expenses
15. List any future anticipated expenses
16. List any damage or loss of property
17. List any assistance received to date

Any Other Comments

1. Detail anything else important about your case

 

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When you have completed as much of the applicant enquiry form as is applicable to your case, or as your time or circumstances permit, click the send button just once.

A confirmation email will be sent to your email inbox, so be sure to get your email address right.

What’s Next? Victims Of Crime Counseling and Compensation Services will contact you within 2-3 business days to arrange an appointment.