Contact Us

If you need to contact us about a current participant or would like more information about us, please see the contact information to the right.

To make a referral, you can submit the below form online, or download the pdf and email it to [email protected] or fax it to (212) 505-1824.

*PLEASE BE SURE TO HIT THE ORANGE SUBMIT BUTTON AT THE BOTTOM OF THE PAGE AFTER FILLING OUT THE FORM

Contact Information

Phone

646-278-2000

Fax

212-964-5566

Address

636 Broadway
4th Floor
New York, NY 10012

Email

[email protected]

Esperanza Referral Form

Referring Party*

Relationship To Case*

Referrer's Phone*

Client's Name*

Date Of Birth*

Gender*

MaleFemaleOther

Home Address*

Borough*

Zip Code*

Home/Cell Phone(s)*

Parent(s)/Guardian(s) Name(s)*

Name(s) of Client's School(s)/Program(s)*

Court/Case-Related Information

NYSID

Docket/Indictment Number(s)

Charge(s)

Judge

Borough

Part

Defense Attorney Name/Phone

ADA Name/Phone

Next Court Date On/For

If VOP, P.O.'s Name/Phone

Reasons For Violation

Original Sentencing Judge/Sentence Imposed

Reasons For Referral/Additional Information

Please attach or fax complaint/indictment, rap sheet and assessments/documents you would like us to review.

Contact Us

Contact Information

Phone

Fax

Address

Email

Contact Information

Phone

Fax

Address

Email

Download Referral Form