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Sudbury District Restorative Justice
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Make a Referral
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Referrer Name
*
First
Last
This is the name of the person making the referral, not the person being referred.
Phone Number
*
Email
*
Referrer Address
*
Referrer Date of Birth
Relation to Referred Individual
*
Self-Referral
Parent/Step-Parent
Relative
Teacher/VP/Principal
Police Service
Legal Services
Child Protective Services (CAS, Kina, Nog, Niij, etc.)
Community Agency
Referral Name
*
First
Last
This is the information of the person being referred to the programs
Referral Date of Birth
*
Referral Address
*
If the same as referrer, just state 'same.'
Referral Email
*
Referral Phone Number
*
Referral School (if applicable)
Has the referral consented to take part?
*
We may require written proof if you are not the guardian and/or self-referring.
Please check which program(s) to which you wish to refer the individual
[Youth] Mediated Restorative Justice Conference
[Youth] Conflict Management Coaching
[Youth] Theft Education Program
[Adult Fee for Service] Eviction Prevention (landlord/tenant mediation)
[Adult Fee for Service] Tenant Dispute Mediation
[Other; fee to be discussed] Custom Programming
Please check any of the potential risks that the individual may be facing
Abuse
Arrested/Charged
Bullying
Challenges accessing services (i.e. no health card)
Developmental Disability
Gang Involvement
Group Home/Foster Care
Homelessness
Human Trafficking
Language Barrier/Immigrant/Refugee
Mental Health
Negative Peer Group
Neurodivergent
Physical Disability
Physical Health
Poverty
Runaway/Missing
School Attendance/Suspensions
Self-Harm
Substance Use
Suicide
Does the referred individual identify as...
Indigenous
Métis
Inuit
Francophone
LGTBQ+
Transgendered
Person of Colour
Newcomer
Has the individual been arrested, charges laid, appeared in court?
Pre-Arrest Diversion
Arrested
First Appearance in Court complete
Please describe the conflict prompting the referral
What is your hope regarding the outcome of this program?
*
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