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

Referring individual

Are you law enforcement officer?

No Yes

If yes: which department?

Phone number?

Relationship to the parties involved

Is there a criminal case pending for this incident?

No Yes

If yes, do you have a case number?

Responsible Party (Person who caused the harm)/ Person Involved

Offender Name *

Date of birth

Phone number *

Address (include zip code)

Is this person a minor?

No Yes

If yes, Parent name and phone number *

Language spoken?

English Spanish

Other

Other Party/ Person who was harmed

Name

Date of birth

Phone number

Address (include zip code)

Incident Information

Date of the incident

Brief description of the incident (what happened?, why is there a conflict?)

Describe relationship if parties involved are acquainted

Are there any material damages? Briefly describe

Comments/Additional Information

If you can see this field, please leave it blank

Victim Offender Dialogue Referral

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