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2. INSTRUCTIONS:
   • Use this form to make a referral to any of CJRD’s diversion or deflection programs, regardless of your role in the system. Fields marked with an asterisk are required.
   • Provide the referred individual with the name and contact information for the applicable CJRD Diversion/Deflection Coordinator listed in Section V, and direct the referred individual to contact the Coordinator within 72 hours.
   • NOTE TO LAW ENFORCEMENT:
     •  Attach a copy of the Incident Report and/or provide a detailed description of the incident in the space provided in Section III.
     • Please consult with your agency’s designated law enforcement liaison(s) to determine if they prefer that all referrals go through them. If you are not your agency’s designated law enforcement liaison, please submit a copy of this form to your agency liaison.
4. I. Individual Being Referred
6. Name*
7. Date of Birth*
8. Phone #
10. Email
11. Address
13. Race/Ethnicity

    Check all that apply

    1. American Indian/Alaska Native
    2. Asian
    3. Black/African American
    4. Hispanic/Latino

    1. Middle Eastern/North African
    2. Native Hawaiian/Pacific Islander
    3. White
    4. Prefer Not to Answer/Unknown
14. Race/Ethnicity response based on:

    1. Self-reporting
    2. Best guess
16. Gender Identity

    1. Male
    2. Female
    3. Transgender
    4. None of These
17. Gender Identity based on:

    1. Self-reporting
    2. Best guess
19. Living Unsheltered?

    1. Yes
    2. No
    3. Unknown
20. UNC Student?

    1. Yes
    2. No
    3. Unknown
21. Interpreter needed?

    1. Yes
    2. No
    3. Unknown
22. If Yes, What Language?
24. Other Accommodation Needed? (describe)
26. If Under Age 18:
28. Guardian Name
29. Guardian Phone #
30. Guardian Email
31. Guardian Notified of Referral?

    1. Yes
    2. No
    3. Unknown
33. II. Referral Source
35. Name*
36. Phone #*
37. Email*
39. Role*

    Select one. If Other, please specify below.

    1. CHPD
    2. CHPD Crisis Unit
    3. CPD
    4. Defense Attorney
    5. HPD
    6. Jail Medical

    1. Joint Prosecutor and Defense
    2. OCSO
    3. Probation
    4. Prosecutor
    5. UNC-CH DPS
    6. Other
41. Please Specify Other Referral Source
43. III. Incident/Offense Information
45. Local Incident (OCA) #
46. Incident Date*
47. Incident Location*
49. Victim(s) Names(s)
51. Description of Incident/Reason for Referral*
53. IV. Diversion/Deflection Recommendation
55. All Known Charge(s) and Court File Number(s)*
56. Other Potential Charge(s) Not Yet Filed
58. Which Charge(s) are you Referring for Diversion or Deflection?*
59. Current Status*

    1. Pre-charge
    2. Post-charge
61. Applicable CJRD Diversion/Deflection Program(s)*

    Check all that apply

    1. Not Sure (CJRD will determine which program is most appropriate and will follow up with the referral source about connecting to the referred individual
    2. Youth Deflection Program (YDP) (17 and under deflection)
    3. Orange County Pre-Arrest Diversion (OC-PAD) (first offense 18+ deflection)

    1. The Lantern Project (substance use diversion)
    2. Community Care and Diversion Response (CCDR) (serious mental health diversion)
63. V. Staff Contacts
65. CJRD Diversion/Deflection Coordinators

    Name		Program		Email			Phone
    Desmond Frierson		OC-PAD		dfrierson@orangecountync.gov			919.245.2312
    Tami Pfeifer		YDP		tpfeifer@orangecountync.gov			919.698.9130
    Megan Pickard		Lantern		cpickard@orangecountync.gov			336.264.9084
    Myiah Livingston		CCDR		mlivingston@orangecountync.gov			919.268.5468

67. Law Enforcement Liaisons

    Agency	Program		Liaison		Email		Phone
    OC Sheriff’s Office	OC-PAD, Lantern		Capt. Stephen Shaw		stshaw@orangecountync.gov		919.245.2916
    	YDP		Lt. Johnathan McVey		jomcvey@orangecountync.gov		336.223.2163
    	CCDR		Chief Deputy Tina Sykes		trimmer@orangecountync.gov		919.245.2900
    Chapel Hill PD	OC-PAD, YDP, Lantern		Capt. Shane Osborne		sosborne@townofchapelhill.org		919.644.3050
    	CCDR		Sarah Belcher		sbelcher@townofchapelhill.org		919.968.2806
    Carrboro PD	OC-PAD, YDP, Lantern		Sgt. Erasmo Velazquez		evelazquez@carrboronc.gov		919.918.7413
    	CCDR		Capt. Ryan Daniels		rdaniels@carrboronc.gov		919.918.7418
    Hillsborough PD	OC-PAD, YDP, Lantern		Capt. Richard Hooks		richard.hooks@hillsboroughnc.gov		919.296.9524
    	CCDR		Chief Jason Winn		Jason.winn@hillsboroughnc.gov		919.296.9500
    UNC DPS	OC-PAD, YDP, Lantern		Tracy Perry		tllperry@email.unc.edu		919.966.4994
    Eno River State Park	OC-PAD, YDP, Lantern		Park Superintendent  Kimberly Radewicz		kimberly.radewicz@ncparks.gov		919.383.1686

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70. Email address

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