Submit a Case

Referring Officer or Individual *

Referring Agency

Court Case #

Fax / Email Reports To

District Attorney Name

District Attorney Phone

Defense Attorney Name

Defense Attorney Phone

Defense Attorney - Public or Private?

Public Defender Private Council

Probation Officer Name

Probation Officer Phone

OFFENDER(s) SECTION:

(Please include separate information for each offender in joint cases in the box provided for that information)

Offender Name *

Offender Age

Offender DOB

Offender Gender

Male Female

Offender Address (include zip code)

Offender Language(s) Spoken

Offender Phone *

School at Time of Offense (for tracking purposes only)

Current School

Parent / Guardian Name(s)

Parent / Guardian Language(s) Spoken

Parent / Guardian Phone(s)

Joint Offender(s) Information

VICTIM SECTION

Victim Name *

Victim Gender

Male Female

Victim Address (include zip code)

Victim Language(s) Spoken

Victim Phone *

Victim Parent / Guardian Name(s) (if minor)

Victim Parent / Guardian Language(s) Spoken

Victim Parent / Guardian Phone(s)

OFFENSE SECTION

Type of Offense

Date of Offense

Next Court Date

Brief Description of The Incident and Nature of Damages

Describe Relationship If Victim and Offender Are Acquainted

Amount of Court Ordered Restitution (if any)

Comments / Additional Information

Upload Any PDF or Ms-Word Documents Pertinent to Case Max upload size: 5MB

If you can see this field, please leave it blank

Referring Officer or Individual *

Referring Agency

Court Case #

Probation Case #

Fax / Email Reports To

Probation Officer Name

Probation Officer Phone

OFFENDER(s) SECTION:

(Please include separate information for each offender in joint cases in the box provided for that information)

Offender Name *

Offender DOB

Offender Gender

Male Female

Offender Address (include zip code)

Offender Language(s) Spoken

Offender Phone *

Joint Offender(s) Information

VICTIM SECTION

Victim Name *

Victim Gender

Male Female

Victim Address (include zip code)

Victim Language(s) Spoken

Victim Phone *

OFFENSE SECTION

Type of Offense

Date of Offense

Date Probation Supervision Began

Brief Description of The Incident and Nature of Damages

Describe Relationship If Victim and Offender Are Acquainted

Amount of Court Ordered Restitution (if any)

No Contact Order?

No Yes

Comments / Additional Information

Upload Any PDF or Ms-Word Documents Pertinent to Case Max upload size: 5MB

If you can see this field, please leave it blank

Victim Offender Dialogue Referral

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