Help Request - info-radical.org

Please complete this strictly confidential form in order to report any risk-prone situation to the CPRLV, involving a person who is radicalized or in the process of radicalization, particularly:
- when this person displays worrisome behaviours or threatens to be violent toward your family, friends or society at large (e.g. school, community, etc.), giving reason to fear that he or she may pose a danger to an individual's life or safety, or to public safety;
when you are concerned about the behaviours displayed by this person and would like to benefit from support offered by the Center (e.g. listening, advice, information).

Your request will be processed speedily and a CPRLV member will contact you at the earliest opportunity.

Identification of the person making the report

First Name

Last Name

City

Phone number (home and office)

Phone number (cell)

Information on the reported person (or group)

First name

Last name

Minoradult

City

Phone number (home and office)

Phone number (cell)

Describe – in as much detail as possible – what you believe to be a violent radicalization situation (Who? What? Where? How? Why?)

What is your relationship with the reported person?

Father / mother

Brother / sister

Teacher / educator

Social worker / community worker

Other, specify

Have you already made this report to another organization?

If yes, which?

It is possible that your report does not fall within the CPRMV's mandate. If this is the case, do you authorize the CPRMV to refer the information you have transmitted to us on this form to resource persons who can help you? (e.g. community organizations, CLSC, Emploi Québec, etc.)

YesNo

We strive to offer you a service that is best suited to your situation. Unless you advise us otherwise, we assume you agree that the information pertaining to your request for service be shared between our professionals and this, in accordance with the rules of confidentiality.