Support and report Request Form

You can fill out this form to communicate with the professionals at CPRLV and make a request for assistance or a report. Your request may concern any situation involving a person in a situation/process of radicalization or acts of a hateful nature for which you wish to receive assistance or any situation where you believe you have been a victim or witness of a hateful act.

Your request will be treated in complete confidentiality by a professional of the CPRLV. If you consent below, a CPRLV professional will contact you.

Name

First name

City

Phone number

Do you consent to CPRLV being able to contact you for a follow-up in relation to your request / report?

YesNo

• Can our professionals mention the CPRLV in their emails or in a voice message that will be sent to you?

YesNo

Describe the reasons for your request (assistance, reporting, etc.) or the situation for which you wish to call upon CPRLV?

Unless you tell us otherwise, you consent to the sharing of your application information among our professionals in accordance with the rules of confidentiality. For any emergency involving the safety of an individual or the community, please call 911.

If you wish to share content (images, videos, screenshots, texts, etc.) related to your request, you can do so by uploading these files below.

Have you made a request or a report regarding the situation described to another agency (police, 811...)?

If yes, which one?

It is possible that your request does not fall within the mandate of CPRLV. If this is the case, do you authorize the CPRLV to share the information you have provided in this form with resources that can help you (health professionals, community organizations, etc.)?

YesNo