• Restorative Response Baltimore (RRB) Universal Intake & Referral Form

    Share what’s happening, who’s involved, and what support you’re seeking so RRB can determine next steps.

  • Before You Begin

  • Privacy and Safety Notice
  • Do you have any questions or concerns about the information above?*

  • About You

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are there any personal circumstances, support needs, or background information you would like RRB to know about that may affect your participation or safety?
  • Pronouns
  • Format: (000) 000-0000.

  • Safe Contact Preferences

  • What are the safest ways for RRB to contact you?*
  • Is it safe to leave you a voicemail?*
  • Is it safe to send you a text message?*

  • How You Were Referred

  • How did you hear about or get referred to RRB?*
  • Format: (000) 000-0000.
  • Does the person or organization referring you expect RRB to provide information back to them?*
  • Deadline, court date, meeting date, or other required date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Other People Involved

  • Please describe other people directly involved in or impacted by this situation. You do not need to label anyone as a victim, offender, or perpetrator.
  • Is another person directly involved?*
  • If known, are there any circumstances or support needs RRB should be aware of for this person? Please only share what you reasonably know and do not guess.
  • Information about other people involved
  • Are any additional people involved or impacted?*
  • Additional people involved or impacted
  • Are any children or minors involved?*

  • Tell Us What Happened

  • Please describe the situation in your own words. Share only what you are comfortable providing. You may include important events, dates, circumstances, concerns, or any other helpful details.
  • Is this situation still ongoing?

  • Financial, Property, or Shared Responsibilities

  • Which of the following are involved in this situation?*

  • Impact, Needs & Resolution

  • Current Needs & Well-Being

  • These questions help RRB understand whether additional support may be needed before or alongside a restorative process.
  • Which of these are affecting you or the situation right now?

  • Immediate Safety

  • Is anyone in immediate danger of being seriously harmed right now?*

  • Readiness for a Restorative Process

  • Which statements best describe how you feel right now?*

  • Outside Referral Support

  • Would you like RRB to discuss referral options if another organization may be better able to meet some of your needs?*
  • What type of additional support may be helpful?

  • Restorative Response Baltimore (RRB) Universal Intake Discovery Call

    Please select a day and time to discuss next steps.

  • Your Information-Sharing Choice

  • You are in control of how RRB shares your information with outside organizations. Choose the option below that best reflects your preference for sharing information with trusted partners or keeping it within RRB.
  • How may RRB share your information?*

  • Final Information

  • What is your preferred next step?*

  • Final Acknowledgment

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: