Delta State University, Abraka

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Name (Optional)

Nature of Abuse *

Physical Abuse

Verbal/Emotional Abuse

Sexual Assault

Stalking

Relationship to Perpetrator *

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Family Member

Stranger

Acquaintance

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Date/Time of Incident *

Location of Incident *

Description of What Happened *

Any physical injuries sustained *

Did the victim seek medical attention? *

Did the victim report to authorities? *

Support Needed *

Counseling

Legal Assistance

Medical Assistance

Other

Were there any witnesses?

Contact information of witnesses (if available)

Any other information the victim wishes to share

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