Justice Referral Form

You do not need to have all of the details to make a referral. This form is simply a way to let us know that someone may benefit from a restorative justice process. A member of our team will contact the people involved to learn more about the situation, answer questions, and explore whether a restorative approach may be appropriate.

Referring Agency:

Referring Person:

Phone Number:

Email Address

Date of Referral:

Date of Incident:

Location of Incident:

Incident Details: (Reason for the Referral)

Police File Number:

Potential Charge:

Officer Involved:

Officer Contact Info:

Court Date:

Docket Number:

Crown Prosecutor:

Contact Info:

Defense Counsel:

Contact Info:

RESPONSIBLE PERSON INFORMATION (Person Who Caused Harm)

Legal Name:

Preferred Name:

Gender:

DOB:

Phone Number:

Email:

Address:

If Minor, Parent or Guardian Name:

Contact:

School:

Principal Name:

Principal Contact:

Current supports in place, if known:

Please share any previous challenges related to this incident or any safety considerations we should be aware of before moving forward.

*Participation in Restorative Justice is a voluntary process.
The Responsible Youth must accept responsibility to qualify for Restorative Justice.

AFFECTED PARTY INFORMATION (Person Who Was Harmed)

Legal Name:

Preferred Name:

Gender:

DOB:

Phone Number:

Email:

Address:

If Minor, Parent or Guardian Name:

Contact Information:

School:

Principal Name:

Principal Contact:

Current supports in place, if known:

Please share any previous challenges related to this incident or any safety considerations we should be aware of before moving forward.

*Participation in Restorative Justice is a voluntary process.
The Harmed Party can choose accept to decline participation in the Restorative Justice process.