Justice Referral Form

Referring Agency:

Originating Detachment:

Type of Referral:

Date of Referral:

Court Date:

Docket Number:

Date of Offence:

Type of Offence:

Officer Involved:

Officer Contact Info:

Police File Number:

Is referring officer willing to participate in the Restorative Justice Conference or Restorative Practice?

Yes No

Crown Prosecutor:

Contact Info:

Defense Counsel:

Contact Info:

Judge / Justice:

Probation Officer:

Agencies or Support Services:

OFFENDER INFORMATION (Person Who Caused Harm)

Legal Name:

Preferred Name:

Gender:

DOB:

Phone Number:

Email:

Address:

If Minor, Parent or Guardian Name:

Contact:

Has the offender agreed to be contacted by RRDRJ?

Yes No

VICTIM INFORMATION (Person Who Was Harmed)

Legal Name:

Preferred Name:

Gender:

DOB:

Phone Number:

Email:

Address:

If Minor, Parent or Guardian Name:

Contact Information:

Has the victim agreed to be contacted by RRDRJ?

Yes No

INCIDENT INFORMATION

Provide details of incident and anything you think is important for the case worker to know regarding the people involved: