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Death Victim Impact Statement

Name:		C.T. No.:
Full Address:		State V.
Phone (Home):		Case Coordinator:
Phone (Work):
I. Relationship

1. How were you related to the victim?

2. How has this loss affected you: a) Emotionally?
b) Your relationship with others (family members, friends, outside people)
c). Financially
3. Are you seeking any type of counseling?
II. Children

1. Are there any surviving children?

2. Has there been a noticeable effect on any or all of the children?
3. Are the children going to any type of counseling?