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Community, School, or Organizational Conflict Referral Form

Restorative Justice Conferencing is a voluntary process offered as an alternative to the traditional justice system that allows for community derived solutions and opportunities to repair harm. You'll see on the form that we ask for contact information for participants, and that we ask about their relation to the harm that occurred. We know that the question of who caused harm to whom can be tricky in some settings. Fill the form out as best you can. We understand that life and harm are often muddier than a simple form can convey. Prior to filling out this form, please notify all parties that they have been referred for this process. After receiving this referral, parties will be contacted within three business days. You, as the referrer, will be updated throughout the process. If you need any assistance filling out this form, please contact us at 7168101038 ex 2 or email at ecrjc567@gmail.com Thank you.

Are you the main contact person for this Restorative Conference?
Where did the harm take place?
  • {name}
Description of Harm/Conflict
Please be as specific as possible. What happened? Is the conflict or harm ongoing? Who was involved? When did this happen or start? Where did the harm occur? If you know, what caused the incident?
  • {name}
How many people were directly impacted by the harm or conflict?
If you (the referrer) were involved, please include yourself as well!
Where all participant notified?
Are there any time constraints we should be aware of?
To the best of your knowledge, are there any legal restraints to a Restorative Conference?
Legal restraints include but are not limited to: orders of protection, cease and desists, court cases, civil suits, etc
Will any participants need interpreters?
12) Are there any physical accessibility needs we should take into account to ensure we address all ranges of mobility?

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