Intake Form

RJ Services

Thank you for requesting a restorative justice process for this conflict. Please provide as much information as you can so we can best handle your matter.

* Required

Person Referring Case Name

Person Referring Case Email

Person Referring Case Phone Number

Party 1 Name:*

Required

Party 1 Email:

Party 1 Phone Number:*

Required

Party 1 Address:

Party 1 Date of Birth

Party 1 Race

Party 1 Household Income:

Parent Name if Party 1 is under 18 years old:

Party 2 Name:

Party 2 Email:

Party 2 Address:

Party 2 Phone Number:

Party 2 Date of Birth

Parent Name if Party 2 is under 18 years old:

List Other Involved Parties' Name and Phone Number:

Do either party live or work in a NYCHA development?*

Required

If yes, please state the name of the development here.

Description of Incident:*

Required

Relationship of Parties:

County

Filed in Court?*

Required

If yes, please select:

Adjournment Date

Docket Number

Defense Counsel Name, Email, and Phone Number

If applicable, ADA Name, Email and Phone Number

Is there an Order of Protection?

Yes

No

Are there any accommodations that you need or would like us to know about?

How did you hear about us?

Notes: Please do not include any URLs in the form. You might have to click "submit" twice.