DJS Referral - Conflict Resolution Center of Baltimore County

Date of Referral:*
Month
Day
Year
DJS Identification No#*
DJS Office Location*
Respondent #1
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Parent/Guardian Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Day Phone*
Cell Phone
Other Phone
Complainant
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
Gender*
Parent/Guardian Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Day Phone*
Cell Phone
Other Phone
Complainant #2 -or- Respondent #2
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
Gender*
Parent/Guardian Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Day Phone*
Cell Phone
Other Phone
Case Manager
First Last
Phone w/ ext:
Email
Brief Incident Description*
Date of Incident:
Referring DJS Staff*
First Last
Phone*
Email*
CAPTCHA

58280

Thank you for your referral. We have reached capacity for the remainder of the year. This case will be opened in January 2025.

*Please Note: Our office will be closed for winter break from December 19th through January 1st. If you reach out during that time, we will look forward to responding promptly when we reopen on January 2nd. Thank you.*

Respondent #1

Complainant

Complainant #2 -or- Respondent #2