EDRT Service Request Registration Form

Program Overview

The District of Columbia Office of Victim Services and Justice Grants has partnered with Give an Hour to develop the Enhancing the District's Response to Trauma (EDRT) project. This project provides connection to free and confidential trauma-specific mental health services. To maintain funding, Give an Hour must collect data for anonymous tracking and project improvements. Your personal information will be kept confidential.

Eligibility Requirements

To receive services through EDRT, you must:

Be at least 5 years of age
Be a resident of the District of Columbia or have been a victim of a crime that occurred in the District of Columbia.
Fall into one of the following categories:

Victim of crime
Justice-involved adult or juvenile
Youth at risk of truancy or juvenile delinquency
Family member/loved one of someone in one of the categories above

Client or Referring a client?

Referrer Information:

Referrer Name

Referrer Phone

Referrer Email

Relationship to the Client

Client Information:

First Name

Last Name

Email Address

Phone Number

State

Zip Code

Date of Birth (MM/DD/YYY)

Primary Language

Will language access services be needed?

YesNo

Victim Type

Primary Victim (directly impacted by crime)Secondary victim (family member/loved one of a victim)

Reason for seeking services

What type of services are you interested in? (Hold the CTRL key to select one or both)

Current Issues/Concerns (Hold the CTRL key to select all that apply)

History of Trauma?

YesNoUnsure

Category of Crime(s) (Hold the CTRL key to select all that apply)

Have you engaged with any of the following systems? (Hold the CTRL key to select all that apply)

How did you hear about Give an Hour's EDRT Program?

Social Media (e.g.: Facebook, Instagram, X) Personal Recommendations (e.g.: friend, family member, colleague) Healthcare Providers (e.g.: therapist, doctor) Online Web Search (e.g.: Google, Bing) Educational Institutions Community and Military Organizations Media Events and Conferences Other

Need More Help? Email us at referrals@giveanhour.org