🧾 1. Basic Information

Date of Incident:
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Approx. Time of Incident:
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City / Area:
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Location Type:
Street / OutdoorHotel / MotelPrivate ResidenceCarOnline Meetup

🚨 2. Description of the Person (if known)

Name / Alias (if known):

Physical Description:

Gender:

Approx. Age:

Height:

Build:

Hair:

Eyes:

Distinguishing features (tattoos, scars, accent, etc.):

Vehicle Information:

Make/Model:

Color:

License Plate (if known):

Phone Number / Online Handle:

Where the contact happened:

Website / App (specify):

StreetReferralRegular Client

Other:

⚠️ 3. What Happened

Type of Incident (check all that apply):
Physical assaultSexual assaultVerbal threats or harassment"Theft / Refusal to payStalking / FollowingIntoxicated or aggressive behavior

Description of the Incident:

Were weapons involved?
YesNoUnsure
If yes, describe:

💬 4. After the Incident

Did you report to police or another organization?
YesNo

If yes, which one?

Do you want this report shared publicly (e.g., bad date list)?
Yes – anonymouslyNo – for record onlyUnsure

🧡 5. Optional Contact (only if you want follow-up)

First Name / Alias:

Safe Contact Method (phone, text, email, outreach worker):

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⚠️ Submitting this report does not replace emergency services. If you are in immediate danger, call 911 or your local emergency line.