Name of parent or guardian

Name of child

Name of Defendant

1. Has your child been emotionally affected by this crime? If yes, you may wish to discuss how the crime may have affected your child's relationships with you, family members, and those close to you. If your child received any form of victim services such as counseling by either a licensed professional, member of the clergy or a community-support group, you may wish to mention this. Please use additional paper as necessary.

2. Was your child physically injured or hurt as a result of this crime? If yes, you may wish to write about the type of injuries your child had, what medical treatment your child received, and how long these injuries lasted or are expected to last. Please use additional paper as necessary.

3. Has this crime affected the way your child relates to his or her friends, either at school or in your neighborhood? Has this crime affected your child's school work in any way? Please use additional paper as necessary.

4. How has this crime affected you, your family and those close to your child? You may wish to write about changes that may have occurred in your family, in your ability to perform your work, make a living, run a household or enjoy any other activities you enjoyed before the crime. You may also wish to include any victim services or counseling that you and those close to your child have received. Please use additional paper as necessary.