Manitoba Victim Impact Statement Form Page 2

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PLEASE COMPLETE THE FOLLOWING SECTIONS
(Please print or write clearly. If you need more space, please attach additional pages.)
1. Emotional Impact:
Please describe how the crime has affected you emotionally.
Consider the effect of the crime on your life. For example:
• emotions, feelings and reactions
• spiritual feelings
• lifestyle and activities
• relations with your partner, spouse, friends, family or colleagues
• ability to work, study or attend school
• counselling or therapy provided
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
2. Physical Impact:
Please describe any physical injuries or disabilities that you suffered because of
the crime. For example:
• pain, hospitalization, surgery you have experienced because of the crime
• treatment, physiotherapy and/or medication you have received
• ongoing physical pain, discomfort, illness, scarring, disfigurement or physical
restriction
• need for further treatment, or expectation that you will receive further treatment
• permanent or long-term disability
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

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