Form Center

2. Name of individual Referred
3. Date
4. Date of Birth
5. Phone Number
7. Address
8. UNC Student?

   1. Yes
   2. No
9. Local Incident Number
11. Charges:
13. District Attorney;
14. Contact:
16. Defense Attorney:
17. Contact:
19. Diversion Coordinator:
20. Contact:
22. Please Check Diversion Program

    1. Lantern Project (Behavoiral Helath/Harm Reduction)

    1. Mental Health Diversion (CCDR Team)

    1. OC-PAD (first offense 18+)
24. I agree to have this matter referred to the above diversion program and I understand that I may be charged and/or prosecuted for the offenses(s) listed above if:
    • I fail to contact the Diversion Coordinator within 72 hours
    • I fail to complete my diversion program plan within the designated time
    • I am charged with any offense prior to the successful completion of the diversion plan
26. Signature of Individual
27. Date
29. Signature of District Attorney

    (If applicable)

30. Date
32. Signature of Defense Attorney
33. Date
35. Next Court Date
37. Lantern Project Diversion Coordinator

    Megan Pickard

    Phone: (336) 264-9084

    Email: cpickard@orangecountync.gov

38. Mental Health Diversion Coordinator

    Ashley Machado

    Phone: (919) 268-5468

    Email: amachado@orangecountync.gov

    
    

39. OC-PAD Diversion Coordinator

    Desmond Frierson

    Office: (919) 245-2312

    Mobile: (336) 212-5883

    Email: dfrierson@orangecountync.gov

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field