Victim support registration form

Do you need assistance with a criminal case in which you are the victim? We invite you to a free intake interview to assess how we can assist you.

You may have been referred to this intake form by our office, or you may have found it yourself. By completing the form below, we can make a good assessment of whether we can assist you and whether an intake interview at our office would be beneficial. If the interview is already scheduled, our lawyers can prepare adequately based on the information you provide. Rest assured that we will treat the information you provide confidentially. Thank you in advance for completing the form!

Registration Form

Personel data

Gender

First names

Last name

Date of birth

Citizen service number (BSN)

Street

Number

Postal code

Residence

Phone number

E-mail address

Partner

If partner: Gender

If partner: First names

If partner: Last name

If partner: Date of birth partner

If partner: Citizen service number (BSN) partner

Legal insurance

Insurer name

Policy number

Criminal act

Date of offence

Declaration

Parquet number

Hearing date

Brief description of criminal offence

What is your injury (mental and/or physical)?

Agree to terms and conditions and privacy and cookie statement before sending.

After completing this form, your request will be sent to our office. This does not mean that your case has already been taken on by one of our lawyers. As long as you have not yet received and signed an order confirmation, you are responsible for responding in a timely manner to any (appeal) deadlines. I understand this.

Noordanus AdvocatuurVictim support registration form