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Victim Rights Law Center Online Client Application

Home · How VRLC Can Help · Victim Rights Law Center Online Client Application

Application for Services

1Acknowledgement

2Basic Information

3Immigration Practice Acknowledgement

4Family Law Practice Acknowledgement

5Acknowledgement

6Acknowledgement

7Acknowledgement

8Acknowledgement

9Survivor Name

10Perpetrator Information

11Survivor Demographics

12Survivor Contact Information

13Upcoming Hearings

In order to apply, you will need to give us personal information about yourself, your household, and the nature of your legal problem.

We only use this information to figure out if you qualify for our legal aid services. We will not share any of this information without asking you first.

Please understand that submitting an application does not guarantee that Victim Rights Law Center can take your case. Submitting an application does not create an attorney-client relationship.

Acknowledgement(Required)

I understand and would like to continue.

I am looking for help with...(Required)

Please note that VRLC's services are limited to survivors of rape, sexual assault, and stalking of a sexual nature. If you are not sure if you qualify, please select "Unsure."

Rape

Sexual Assault

Stalking of a sexual nature

Unsure

Something Else

Please provide a brief description.(Required)

Is your legal issue in Massachusetts?(Required)

If you are unsure, but you live in Massachusetts, please select "yes."

Yes

No

Are you applying for services for yourself or for someone else?(Required)

Myself

Someone else

What is your relationship to the survivor?(Required)

Parent/Guardian

Advocate or other referring agency

Family member

Friend

Other

Is the survivor aware that you are applying for services on their behalf?(Required)

Yes

No

Is the survivor under the age of 18?(Required)

Yes

No

Please select the legal area(s) you are looking for help with.(Required)

Privacy

Safety

Protection Order (258E/209A)

Education (in a K-12 school)

Education (in college or other higher education)

Immigration

Housing

Employment

Applying for Victim Compensation or Public Benefits

Name or Gender Change Petitions

Navigating the Criminal Justice System

Family Law (divorce or child custody)

I'm not sure

Please note that VRLC is unable to take new immigration cases, but may be able to help with your other legal concerns. Our team will still provide referrals for help with Immigration matters.

Acknowledgement(Required)

I understand and would like to continue the application.

I am only looking for help with immigration and would like referrals.

Please note that VRLC is unable to practice family law, but may be able to help with your other legal concerns. Our team will still provide referrals for help with family law.

Acknowledgement(Required)

I understand and would like to continue the application.

I am only looking for help with family law and would like referrals.

Our team must speak to survivors directly. You may proceed with entering information, but know that, for most survivors (including most minors), we will need to speak with them directly to discuss their legal goals.

Acknowledgement(Required)

I understand and would like to continue the application.

Our team must speak to survivors directly. You may proceed with entering information, but know that, for most survivors (including most minors), we will need to speak with them directly to discuss their legal goals.

Acknowledgement(Required)

I understand and would like to continue the application.

Our team must speak to survivors directly. You may proceed with entering information, but know that, for most survivors (including most minors), we will need to speak with them directly to discuss their legal goals.

Acknowledgement(Required)

I understand and would like to continue the application.

Our team must speak to survivors directly. You may proceed with entering information, but know that, for most survivors (including most minors), we will need to speak with them directly to discuss their legal goals.

Acknowledgement(Required)

I understand and would like to continue the application.

Please list your name.(Required)

First Last

Please list your name.(Required)

First Last

Please list your organization, if applicable.

Please list your phone number.

Please list your email.

Please list the name of the survivor who is looking for help.(Required)

First Last

The next section asks for information about the person who committed the assault or stalking. Please list any information you have, even if that is only their first name or a nickname.

If you are uncomfortable providing this information online, please call our intake line at (617) 399-6720 x19.

Please list the name of the person who perpetrated the sexual assault or stalking(Required)

If the person was a stranger, please list "Stranger" or "Unknown."

Name

Please list the perpetrator's approximate age.

Please leave this blank if you do not know.

Please list the perpetrator's location.

Please leave this blank if you do not know.

City State / Province / Region

This section will ask for information about you.
Please note: your responses will not affect whether or not VRLC is able to help you. This information is gathered for demographic purposes only.

You may choose not to answer right now. If you qualify for VRLC services, our team will gather this information during a phone intake instead.

This section will ask for information about the survivor.
Please note: your responses will not affect whether or not VRLC is able to help the survivor. This information is gathered for demographic purposes only.

You may choose not to answer right now. If the survivor qualifies for VRLC services, our team will gather this information during a phone intake instead.

Please list the survivor's pronouns.

Please list your pronouns.

Please list the survivor's birth date, including the year.

If you do not know the survivor's exact birth date, please enter their age (or approximate age) below.

MM slash DD slash YYYY

Please list the survivor's age.

Please list as an approximation if you do not know their exact age or birth date.

Please list your birth date.

MM slash DD slash YYYY

Please list your gender.

Please list the survivor's gender.

Please list your sexual orientation.

Please list survivor's sexual orientation.

Please list the survivor's race or ethnicity.

Please select all that apply.

American Indian/Alaskan Native

Asian

Black

Native Hawaiian/Pacific Islander

White

Hispanic/Latino(a)

Other

Please list your race or ethnicity.

Please select all that apply.

American Indian/Alaskan Native

Asian

Black

Native Hawaiian/Pacific Islander

White

Hispanic/Latino(a)

Other

Do you identify as having a disability?(Required)

Yes

No

Prefer not to answer

Does the survivor identify as having a disability?(Required)

Yes

No

Unsure

Prefer not to answer

Please list any accommodations VRLC can provide that would make it easier to engage in the legal process.

What is the survivor's approximate monthly income?

What is your approximate monthly income?

What kind of housing does the survivor live in?

What kind of housing do you live in?

How may our team contact you?(Required)

Phone

Text

Email

Mail

How would you prefer our team contact you?(Required)

Phone

Text

Email

Mail

How may our team contact the survivor?(Required)

Phone

Text

Email

Mail

How would the survivor prefer to be contacted?(Required)

Phone

Text

Email

Mail

Phone Number(Required)

Is it safe to text this number?(Required)

Yes

Yes, but please do not indicate that you're calling from VRLC

No

Is it safe to leave a message at this number?(Required)

Yes

Yes, but please do not indicate that you're from VRLC

No

Email Address(Required)

Is it safe to send an email to this address?(Required)

Please note that emails from our team will indicate that we are reaching out from VRLC.

Yes

No

What is your street address?

Street Address Address Line 2

What is the survivor's street address?

Street Address Address Line 2

City/State(Required)

City State / Province / Region

Is it safe to send mail to this address?(Required)

Note: we will never send you mail without notifying you first.

Yes

Yes, but please send any mail in a blank envelope that does not mention VRLC

No

Is it safe to send mail to this address?(Required)

Note: we will never send mail without notifying the survivor first.

Yes

Yes, but please send any mail in a blank envelope that does not mention VRLC

No

What is your primary language?(Required)

English

Spanish

Portuguese

American Sign Language

Other

What is the survivor's primary language?(Required)

English

Spanish

Portuguese

American Sign Language

Other

Will you need a translator?(Required)

Yes

No

Will the survivor need a translator?(Required)

Yes

No

Does the survivor have an upcoming court or hearing date?(Required)

Yes

No

Unsure

Do you have an upcoming court or hearing date?(Required)

Yes

No

Unsure

Please upload any paperwork you may have for the upcoming hearing or court date.

Max. file size: 2 GB.

If you have any additional information (e.g. docket number or court name), please list it here.

Please list the court or hearing date.(Required)

MM slash DD slash YYYY

What is the court or hearing date for?(Required)

Please upload any additional relevant paperwork or information.

Max. file size: 2 GB.

Contact Us

Address:
11 Beacon Street, Suite 520
Boston, MA 02108

Phone:
(617) 399-6720

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By submitting this form, you are consenting to receive marketing emails from: Victim Rights Law Center, 11 Beacon Street, Suite 520, Boston, MA, 02108, US, https://www.victimrights.org. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact.

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