DJS Referral - Conflict Resolution Center of Baltimore County

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Date of Referral:*
Month
Day
Year
DJS Identification No#*
DJS Office Location*
Participant #1
Participant #1 Type
- Respondent
- Complainant
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
- Black, AA, African
- Asian Am, PI, Asian, South East Asian
- White, Caucasian, European
- Hispanic, Latino, Latina, Latinx
- Native American, American Indian, Indigenous
- Other Identity
- Unknown
- Middle Eastern, North African
- Multi-racial, Multi-ethnic
Gender*
Parent/Guardian Name*
First Last
Relationship to Participant*
Address*
Street Address Address Line 2 City State ZIP Code
Email
Day Phone*
Cell Phone
Other Phone
Participant #2
Participant #2 Type
- Respondent
- Complainant
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
- Black, AA, African
- Asian Am, PI, Asian, South East Asian
- White, Caucasian, European
- Hispanic, Latino, Latina, Latinx
- Native American, American Indian, Indigenous
- Other Identity
- Unknown
- Middle Eastern, North African
- Multi-racial, Multi-ethnic
Gender*
Parent/Guardian Name*
First Last
Relationship to Participant*
Address*
Street Address Address Line 2 City State ZIP Code
Email
Day Phone*
Cell Phone
Other Phone
Participant #3
Participant #3 Type
- Respondent
- Complainant
Name
First Last
Date of Birth
MM slash DD slash YYYY
Race
- Black, AA, African
- Asian Am, PI, Asian, South East Asian
- White, Caucasian, European
- Hispanic, Latino, Latina, Latinx
- Native American, American Indian, Indigenous
- Other Identity
- Unknown
- Middle Eastern, North African
- Multi-racial, Multi-ethnic
Gender
Parent/Guardian Name
First Last
Relationship to Participant
Address
Street Address Address Line 2 City State ZIP Code
Email
Day Phone
Cell Phone
Other Phone
Additional Participant Details
Please list details on any additional participants here. Be sure to indicate if they are respondent or complainant.
Case Details
Case Manager
First Last
Phone w/ ext:
Email
Brief Incident Description*
Date of Incident:
Please upload any associated documents
Max. file size: 512 MB.
Referring DJS Staff*
First Last
Phone*
Email*
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Thank you for your submission; we will be in touch within two business days. If you do not hear from us in that time, please call 443-297-7897.

Participant #1

Participant #2

Participant #3

Additional Participant Details

Case Details