2. Add an Agency Request Form for the Juvenile Justice Resource Database
   When you submit your agency request, it will be entered into our master database after verification. After an initial assessment by our Support Department, the entries will be assigned to the appropriate service categories.
4. Agency Name*
6. Agency Address*
8. City*
9. State*
10. ZIP Code*
12. Primary Contact Person Name*
13. Contact Phone Number*
15. Phone Number Public is to Call*
16. Fax Number
18. TTY/TDD Number
20. Email Address*
21. Agency Website
23. Service Category*

    Check categories of services available at your facility.

    1. Advocacy/Mentoring
    2. Educational Alternative
    3. Health
    4. Self-Help/Support Groups
    5. Drug/Alcohol Treatment
    6. Emergency Crisis
    7. Residential Care
    8. Counseling
24. Languages Spoken at Your Facility

    1. English
    2. Spanish
    3. German

    1. Polish
    2. Other
26. Please include a brief description of your agency's services.
28. Your Name*
29. Phone Number*
31. Email Address*
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field