Submit Referral - Restorative Response

Please fill out the form below to submit a referral for Restorative Response.

Your Name *

Your Email *

Your Phone Number (optional)

Referral Source *

Conflict Date (optional)

Please select the date when the conflict occurred

Referral Reason *

Briefly describe the reason for this request (max 255 characters) (Description of the harm, Previous attempts to repair (if any), Desired outcomes)

People Involved

Enter case participants here.

First Name *

Last Name *

Role *

Phone Number *

Date of Birth *

Gender *

Ethnicity *

Minor *

Address Line 1 *

Address Line 2

Address Line 3

Town/City *

County

Country

Zip Code *

Agreed to RJ

Additional Comments (if Role is Other please specify here) (optional)

Attachments (optional)

Accepted formats: PDF, DOCX, JPG, PNG. Maximum size: 8MB per file.

A conflict resolution and community building organization

https://www.restorativeresponse.org

Restorative Response Baltimore is a conflict resolution and community building organization that provides ways for people to collectively and effectively prevent and resolve conflicts and crime.

Consent

Thank you for your interest in Restorative Response services.

By providing information, you authorize us to contact you regarding the information provided. Participation in our services is based on a case-by-case basis.

The completion and submission of this form does not obligate you or the people that you declare on this form to participate in RJ interventions. Additionally, the completion of this form does not create a relationship with Restorative Response or its programs.

Restorative Response agrees that the contact information contained in this form will not be shared outside of Restorative Response.

I agree to the above

Need Help?

If you need assistance completing this form, please contact us:

Email: [email protected]

Phone: 301-458-6654

Between the hours of 09:00 and 17:00 EST we will endeavor to respond to your inquiry as soon as possible.