2. 
4. Please complete the online form below to submit your request for the Washington County Assigned Counsel Office to contact you.
   The Washington County Assigned Counsel Office will be in contact with you after we have reviewed the form during office hours. This form is not to be used as a message to request emergency services or services after office hours. Please specify if you would prefer a call or an email for us to contact you. * Indicates a Required Field
6. Filling out this form does not provide you with a Public Defender or take the place of filling out an Application for Assigned Counsel
   By completing this form you will not be assigned a Public Defender. You are required to complete an Application for Assigned Counsel and return to our office. The Application for Assigned Counsel can be found on our webpage or by coming into our office.
8. How Would You Like To Be Contacted?*

   Please select one

   1. Phone Call
   2. Email
10. First Name*
11. Last Name*
13. Address1
15. Address2
17. City
18. State
19. Zip
21. Home Phone Number
22. Cell Phone Number
24. Daytime Phone Number
26. Email Address
28. Please Specify General Inquiry or Request for Service
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

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