Victim Empathy Agency Commitment Form

This portion of this document, including your name, will be available to your referring agency if requested. This document is a commitment or agreement to future behaviors; this document does not reflect any admission or denial of any prior action.

Explain three (3) ways that you commit to better choices moving forward, and how you will keep this incident from occurring again: *

Additionally describe at least two (2) ways you can commit to better, safer choices within your community: (What can you do to reduce risk in your community?) *

Signature *

/s/

please sign with your full name

Date

This portion of this document, including your name, will be available to your referring agency if requested. This document is a commitment or agreement to future behaviors; this document does not reflect any admission or denial of any prior action.

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