2. Network for Overcoming Violence (NOVA) Form
4. Too many families in our communities - and far too many children - have experienced trauma that comes with witnessing or experiencing violence of all kinds. Don't let the hurt take charge. Get help.
6. Please complete the following form and a representative from NOVA will follow up with you.
8. What type of violence did you witness or the person you are inquiring about witness?

   1. Child Physical Abuse
   2. Child Neglect
   3. Child Sexual Assault
   4. Bullying

   1. Hear Gunshots
   2. Media Violence
   3. Fighting
   4. Murder

   1. Drug Use
   2. Domestic/Family Violence
   3. Other
10. If you selected "Other", please specify:
12. When did the violence occur? Please provide best date or time frame when it happened.
14. Are you a Victim?

    1. Yes

    1. No
16. If you answered "No", what is your relationship to the victim?

    1. Parent
    2. Spouse

    1. Friend
    2. Other Family Member

    1. Other
18. If you selected "other", please specify:
20. What type of assistance do you need?

    1. Help with a Domestic Violence Problem
    2. Help with learning more about signs of trauma
    3. To learn what services are available
    4. Counseling
    5. Help completing the Criminal Injuries Fund Application (aka Victims Compensation)
    6. Help with the aftermath of Homicide
    7. Other assistance
22. If you selected "other", please specify:
24. How did you hear about the Network for Overcoming Violence and Abuse? Please select the referral source:

    1. Memphis Police Department
    2. Sheriff's Office
    3. District Attorney's Office
    4. Social Service Agency

    1. Hospital
    2. Word of Mouth
    3. Other
26. If you selected "other", please specify:
28. Please provide your name:
29. First Name:
30. Last Name:
32. Please provide your phone number:
34. Should you wish to be contacted by email, please provide your email address:
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

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