If you wish to download the print-ready version of this form, please click here.

Thank you for serving victims with a compassionate heart!  You have put into action what you have learned.  Now you'll want to tell us what you've experienced. 

As you complete this report, consider a few things:
  • Do not hold back!  The more feedback the better.
  • Carefully remember any commitments you made.
  • Your feedback will assist Victim Relief Ministries to make future deployments better!

If you have any questions while completing this form, feel free to contact us at (972) 400-1163.
Name of VRM Responder:
VRM Certifications (Please choose all that apply)
  • 3 Hour Volunteer
  • Crisis Responder (16 hr Basic Training)
  • Chaplain (16 hr Training + Liscenced/Ordained Minister)
  • Advanced Training
  • CISM Certification
Home Church:
Phone #:
Email Address:
Police Substation
Watch (Patrol) Times:
Officer's Name:
Beat #
Total Hours Served
Incident #1 Information:
Date of Incident
Police Report #:
Description of the Incident:
Did you fill out a referral form for this client?
  • yes
  • no
What services did you provide?
Where/How did you see God at work?
Additional Notes:
Incident #2 Information:
Date of Incident
Police Report #:
Description of the Incident:
Did you fill out a referral form for this client?
  • yes
  • no
What services did you provide?
Where/How did you see God at work?
Additional Notes:
Incident #1 Information:
Date of Incident
Police Report #:
Description of the Incident:
Did you fill out a referral form for this client?
  • yes
  • no
What services did you provide?
Where/How did you see God at work?
Additional Notes: