Court-Related 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. 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 716-810-1038 ext 2 or email at ecrjc567@gmail.com

Referrer Name

Referrer Phone Number

Referrer Email

Is this referral for a:

3 Part Conference
Victim and Offender conference only
3 Part with L.O.R.E Series
L.O.R.E Program

Referring Agency

The Center for Resolution and Justice
Erie County District Attorney's Office
Erie County Probation and Parole
Other (please identify)

Please describe the incident that led to the arrest in as much detail as possible.

When is the participants next court date?

Are there other youth involved in this case?

Are the other youth on the same case being referred for Conferencing?

If so, who? (If Applicable Please add their Contact Info)

{name}

Arrested Participant's Name

Preferred Pronouns if Known

Arrested Participant's Phone Number

If the youth does not have a direct phone number please provide custodians name, number, and relation to the youth

Arrested Participant's Age (Please select range)

10-13
13-15
16-18

What is your current Gender Identity?

Male
Female
Other
Prefer not to say

What other programs or services is the youth receiving?

{name}

Arrested Participant's Full Address

Street, City, State, Zip Code

Parent/Guardian/Caregiver Name

Parent/Guardian/Caregiver Phone Number

Probation Officer's Contact Info

Name, Phone, Email

Has probation assigned additional requirements? If so, what are they? Please provide contact information when possible

{name}

Have all participants been notified of this referral?

Yes
No
Some

Will any participants need interpreters?

Person Who Experienced Harm's Name

(Victim)

Person Who Experienced Harm's Contact Information

(Victim) Phone Number or Email

Field 62

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