Form Page

First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Did you or a loved one suffer sexual abuse at a Los Angeles County facility when you were 18 years old or younger?*

Yes

No

Approximately how old were you when the abuse started?

Approximately when did the first abuse occur?*

Please specify the Los Angeles County location(s) where the abuse occurred?*

MacLaren Hall

Los Padrinos Juevenile Hall

Camp Kilpatrick

Camp Scott

Central Juvenile Hall

Barry J. Nidorf Juvenile Hall

Other LA Juvenile Facility

Was the perpetrator a staff member of the facility (i.e. guard, officer, counselor)?*

Yes

No

Unsure

Can you name or describe the perpetrator?

Yes

No

If you are able, please select the type(s) of abuse that occurred?

No Physical Contact Sexual Harassment

Groping (over the clothes)

Groping (under the clothes)

Attempted Sexual Penetration

Masturbation

Oral Sex

Penetrative Sex

When would be a good time to call you?

Central Time

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I Consent