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2. Name of Individual Referred
3. Incident Date
4. Time
6. Date of Birth
7. Address
8. Phone Number
10. UNC Student?

    1. Yes
    2. No
11. If 17 or under: Guardian name and phone number
12. Notified?

    1. Yes
    2. No
14. Location of Incident
15. Local Incident Number
17. 1st Incident: Offense and Statute
18. 2nd Incident: Offense and Statute
19. 3rd Incident: Offense and Statute
21. Name of Victim(s)
23. (Optional) The referring law enforcement officer provides the following special circumstances, suggestions, and recommendations regarding this individual to the Diversion Coordinator:
25. Referring Officer
26. Agency
27. Email
28. Phone Number
30. Please check diversion program

    1. Lantern Project (behavioral health/harm reduction)
    2. Mental Health Diversion (CCDR team)
    3. Orange County Pre-arrest Diversion (OCPAD - first offense 18+)
    4. Youth Deflection Program (YDP - 17 and under)

    • To the best of my knowledge, this individual is eligible for diversion
    • I have attached a copy of the Incident Report
    • The referred individual has been given contact information for the Criminal Justice Resource Department
32. Officer Signature
33. Date
35. I agree to have this matter referred to the above diversion program I understand that I may be arrested and/or charged and prosecuted for the offense(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 new offense prior to the successful completion of the plan
37. Signature of Individual Referred
38. Date
40. Incident Summary

    Upload a copy of the Incident Summary

42. *Note

    This Referral Form should be submitted, along with the Incident Summary, to your Law Enforcement Liaison ASAP and to the diversion coordinator within 48 hours of the incident.

    Once submitted, the Diversion Coordinator will receive a copy of the referral. However, you must submit a copy of the referral separately to the respective Law Enforcement Liaison.

    After submitting this form, you will be able to print/save a copy.

44. Law Enforcement Liaisons

    Capt. Brian Whitehurst, Orange County Sheriff’s Office – OCPAD, Lantern Project and Mental Health Diversion

    Email: bwhitehurst@orangecountync.gov 

    Phone (919) 245-2916 

    Fax: (919) 732-6403

    Lt. Andre Richmond, Orange County Sheriff’s Office – Youth Deflection Program

    Email: arichmond@orangecountync.gov

    Phone: (919) 245-4030 x25040 

    Fax: (919) 245-6403

    Lt. Todd Harris, Chapel Hill Police Department

    Email: tharris@townofchapelhill.org 

    Phone: (919) 968-2865 

    Fax: (919) 968-2846

    Inv. Erasmo Velázquez, Carrboro police Department

    Email: evelazquez@townofcarrboro.org 

    Phone: (919) 918-7413 

    Fax: (919) 942-4473

    Lt. Charles White, Hillsborough Police Department

    Email: chip.white@hillsboroughnc.gov 

    Phone: (919) 296-9532 

    Fax: (919) 732-2187

    Tracy Perry, Public Safety Records Manager, UNC-CH Police Department

    Email: tllperry@email.unc.edu

    Phone: (919) 966-4994 

    Fax: (919) 962-2572

    Kimberly Radewicz, Park Superintendent III, Eno River State Park

    Email: kimberly.radewicz@ncparks.gov 

    Phone: (919)383-1686

    Fax: (919) 382-7378

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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

* indicates a required field