MF se \UAL ASSAULT CRISIS CENTER CRISIS LINE FORM (} Aizeady sean at sace oftice pare or commacr: 2/29/96 ° seg as SE CALLER'S MAME Dey pce “UTE Fetes brit. Seah (ed - a ADDRESS Le, Mitel o fetes! ad om) ‘couNTY me ——_—_— cues 15 VDaAY VSN arama east PRIMARY vicrIM a Mure a PRIMARY VICTIN’S ADDRESST | SERED HAVING Teornaen __—“bivjaes ———szwany a ‘AGE 2a '.“BaworeaP ; ee ere PROBLEM: we ViGTIN’S MENTAL STATET BERGA RUS NSELENG VEST} wo py WRERE/WETE WEG SEXUAL ASSAGLT/ASUSE OTHER CRIME: ate as ae WHEN DID INcroENT ocota; “shask = erry: oa eae Conwy: = vane OF ASeRTLANE: Se tr AGE RELATIONSET? 70 ViGTTS? Race > agony; > MSAtiawES sais ape RE INSURE: eReporzep: wes (Vf wot} zo maou: i Ly — ewwer (2) Fouzee (ezry) SRERIFE (Cour?) DES (COUNTY) WrGeie Samba "Go FROSECHTE: ves J" wo ¢ ]—GRSTRE MaDe See ae tT ti ASSAILANT ARRESTED: YES [| ] NO STATUS oF PROSECUTION: ——____ MEDTEME TaeATNES ee poe! ROHN |] RVERGE T P00 T T HGPEGML TREATMENT sSoUGHT: —¥ES (] NOC) WHICE mosPraaL: Doctor's sauz: TREASNENT OF VICTIH BICEEEENT (J AVERNGE ( ] pooR t') Helpline ~ crisis eee counseting t Support /Follow-up ( tegal’ [I arranged for Hosp. Accomp. ( ] Bdueacion ( } inrermation 1] DES cRila abuse! [ ] Victio’s comp. mato (] Steiter (violence) {J Ghergency Financial Assistance [J Medical (transportation) { ] haw Entorcenent {_] ceisinal custice syaten advocacy [ ] DRS other ES FOR: {J other (J Adult survivor of child sex abuse Be 0 0 Hx] Adult sexual assause Date Tadtiaiar {CY chia (under age 18) { J cnitd abuse prevention [) other BIGEERI EE vec weathcell nee IN 0064 ENTERED PID nc enna Filed Polk County Clerk of Court 2003-10-15 09:23"Q carn yeliw The,” OD Pot my Seve tomate” " Aewce Phere tt bean crit ” "Mod cemch Letty Tren Sop my E Sen thay i Wl meaad bey eT “Feta beter Cody Uct oped 1 yespe HW Meet rape, Cove op? Rollo ed a toe, Mina, — 1D rade Pag TS beet howell by reas oy 4 Cetin Lik rat ert he ein, Leteth mente. Hepes Fad (pba rt, tron ofr tan Leu JN 0016s Filed Polk County Clerk of Court 2003-10-15 09:23