GET HELP NOW

(614) 445-8131

For immediate or emergency help, please dial 911

    First Name*
    Last Name*
    Phone*
    Email*
    Zip
    Message

    Public Safety Registration Form

    Select from any of the programs listed below and fill out your contact information below.

    Not sure what program is right for you? Learn more about Maryhaven’s public safety & court related programs.

      Personal Information
      Gender*

      Legal Name
      Last*
      First*
      Middle
      Mailing Address
      Street*
      City*
      State*
      Zip*
      Email*
      Phone*
      Age*
      Date Of Birth*
      Social Security #*
      Able to Read and Write English?*
      Language Interpreter / Special Needs / Learning Issues:
      Court / Referral Information
      Enforcement Date:
      Referral Source (Court/School/Other)
      Judge/Magistrate
      Case #
      Probation
      Phone
      Original Charge
      Reduced?
      Reduced To?
      Date of Offense
      Time of Offense
      Arresting Police Dept
      Alcohol/Drug Score
      Prior Arrests or Charges
      Medical
      Special Diet / Medical Instructions
      Smoker?
      Prescriptions & Over the Counter Medicine (e.g name, purpose, length of time prescribed)
      Doctor's Name
      Last
      First
      Phone
      Emergency Contact
      Last*
      First*
      Phone
      Mailing Address (if different from my own)
      Street
      City
      State
      Zip
      Relation*
      Payment Type