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Restorative Justice
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R.J. Inquiry Form
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Client Information
Date
(required)
Your First Name
(required)
Your Last Name
(required)
Mailing Address
(required)
Email Address
(valid email required)
Cell Phone Number
Work Phone Number
Preferred Contact Number
(required)
Are you directly involved in the Harm situation?
Yes
No
Case Information
Please explain briefly what issue(s) you would like to address during a facilitated discussion
(required)
Do you have any apprehension regarding emotional and/or physical intimidation?
Yes
No
If yes, please explain
Other party(s) names(s) and daytime contact information:
First Name: Last Name: Phone Number: E-mail:
What is your relationship to the other party(s)?
Is mediation required by a contract related to this situation?
Are the issues to be addressed via the Restorative Justice process part of a current court case?
Yes
No
If yes, please provide the following
Court
Type of hearing
Hearing date (mm/dd/yyyy)
Case number
Additional Comments/Questions
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