Victim Witness Liaison Referral Form

Referred By

Name

Position

Organization

Address

City

State/Province

Zip/Postal

Phone

Fax

Victim Information

Name

Date of Birth

Address

City

State/Province

Zip/Postal

Phone

Relationship to Accused

Languages Spoken

Interpreter Required

Yes

Parent / Guardian’s Name

(If victim is under 18 years)

Telephone of Guardian

(If different than Victim’s)

Address of Guardian

City

State/Province

Zip/Postal

Alternative

Incident Information

Court File Number (if applicable)

Date of Incident

Investigationg Officer

Badge Number

Incident Number

Force / Detachment

Phone

Summary of Incident

Services Required

Court Information

Court Date

Location

Add Remove

Comments

Referent Consent *

I acknowledge that the above information is correct I also agree to submit this information to Nishnawbe-Aski Legal Services Corporation.