Non-Contact Referral Form

PROGRAM INFORMATION & REFERRAL ACKNOWLEDGEMENT

This referral form is for non-contact restorative justice pathways. Submitting a referral does not guarantee acceptance into the program. All referrals are screened for safety, readiness, and appropriateness. Survivor participation is never required. This program does not replace criminal, child protection, or emergency responses.

Acceptance

I confirm that I have read and understand the above information.

REFERRAL INFORMATION

Referring Agency:

Referring Person:

Phone Number:

Email:

Date of Referral:

Date of Harm or Offence:

INCIDENT DETAILS (Reason for the Referral):

Location of Incident:

Provide details of incident and anything you think is important for the restorative justice facilitator to know regarding the incident, harm caused, and/or the people involved.

Has a report been made to law enforcement?

Yes No

If yes, which detachment:

Police File Number:

Officer Involved:

Contact Info:

Potential Charge:

REFERRED PERSON INFORMATION

Legal Name:

Preferred Name:

Gender:

DOB:

Phone Number:

Email:

Address:

If Minor, Parent or Guardian Name:

Contact:

Current supports in place, if known:

Is there anything important we should know with regard to client safety before moving forward?

Please click Submit to send your responses to ED@rrdrestorativejustice.ca.