School / Community Referral Form

PROGRAM INFORMATION & REFERRAL ACKNOWLEDGEMENT

This referral form is for our restorative justice program. Submitting a referral does not guarantee acceptance into the program. All referrals are screened for safety, readiness, and appropriateness.
Participation in restorative processes is always voluntary. Individuals impacted by harm are never required to participate.
The restorative approach used will be determined by program facilitators in consultation with those involved.
This program does not replace criminal justice processes, child protection, or emergency responses.

Acceptance

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

REFERRAL INFORMATION

Referring Agency:

Referring Person:

Contact Phone:

Contact Email:

Type of Referral:

Date of Referral:

INCIDENT DETAILS (Reason for the Referral)

Date of Incident:

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:

Potential Charge:

RESPONSIBLE YOUTH 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:

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.

HARMED 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:

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 to decline participation in the Restorative Justice process.

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

Special Notes:

Not all referrals to RJ are accepted. We will review the referral form and set up a time to discuss the file with you. This conversation is usually done over the phone or via Microsoft Teams, and takes approximately 15 to 30 minutes.