Victim Advocacy Follow Up

We recognize that often a family has additional needs or questions which arise after they have left Susie’s Place. Thus we ask that you indicate your preference regarding receiving follow up calls below. The purpose of the call is to assist with questions you may have and to ensure you are aware of other community resources that may be helpful to you or your family.

Permission for Follow Up

Do you want Susie's Place to follow up with you?*
- Yes
- No
Your Name*
First Last
Your Child's Name*
First Last
Child's Name (Additional)
First Last
Child's Name (Additional)
First Last
How do you prefer we contact you?
- Phone only
- Email only
- Phone and/or email
Phone Number (If you prefer to receive call)
Is it okay to leave a voicemail at this number?
- Yes
- No
Best Time to Call
Email (if you prefer to receive email)
What county do you live in?
If your child was interviewed at Susie's Place, what is the approximate date your child was interviewed?
MM slash DD slash YYYY
Please list any needs your family has
This is for anything you'd like more information on, like food, counseling, medical care, financial assistance, etc.
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Comments
This field is for validation purposes and should be left unchanged.

Victim Advocacy Follow Up

Permission for Follow Up

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