Referral Forms

Victim-offender Dialogue (VOD) Program

Please fill out this form for criminal cases or if you are one of the following: Law enforcement, Attorney, Public Defender, District Attorney, Probation Officer, Case manager, non-profit employee referring a client, criminal justice stakeholder, or city employee. If you are a community member requesting a mediation, please fill out our community referral form.

REFERRAL INFORMATION

Name of Individual Requesting the Referral:

First Name

Last Name

Referral Individual's Email:

Referral Individual's Phone Number:

Referring Agency:

Public Defender's Office

District Attorney's Office

Probation

Law Enforcement

Other

Is there a court case pending on this case?

If yes, court case #:

Is the offender a minor or is the case being processed in juvenile court?

Offender Information

Offender's Name:

First Name

Last Name

Offender's Age:

Offender's DOB:

YYYY

Offender's Assigned Gender:

Offender's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Offender's Phone Number:

If offender is a minor, please provide the following parent/guardian information.

Parent/Guardian Name:

First Name

Last Name

Parent/Guardian Phone Number:

Language Spoken:

Are there any joint offender’s in this case?

Victim Information

Victim's Name:

Victim's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Victim's Phone Number:

If victim is a minor, please provide the following parent/guardian information.

Parent/Guardian Name:

First Name

Last Name

Parent/Guardian Phone Number:

Language Spoken:

Offense Information

Type of Offense:

Date of Offense:

YYYY

Next Court Date:

YYYY

Brief description of the incident and nature of damages:

Description of relationship, if victim and offender are acquainted:

Amount of court ordered restitution (if any):

Additional Information/Other Comments:

Your Name OR Client's Name:

First Name

Last Name

Email:

Phone Number:

Your Age OR Client's Age:

Preferred Pronouns:

Your Sexual Orientation OR Client’s:

Brief description of the situation and why you are requesting the referral:

Is there anything else you would like us to know or any concerns you may have?

Is there a criminal case pending or was there ever a criminal case on this matter?

Yes

Don't Know

If you are making a referral for a client, please fill out the following section.

Name of Individual Requesting the Referral:

First Name

Last Name

Referral Party's Phone Number:

Referral Party's Email:

Relationship to the Client:

Attorney, case manager, etc.

Restorative Dialogue & Mediation Request

Please fill out this form if you are a member of the community requesting a Restorative Dialogue or Mediation.

Name of Person Requesting Mediation:

First Name

Last Name

Email:

If you are making a referral for someone else, what is your relationship to that person?

PERSON INVOLVED / 1

Name of Person Involved in the Conflict/Matter:

First Name

Last Name

Phone Number:

Email:

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PERSON INVOLVED / 2

Name of Person Involved in the Conflict/Matter:

First Name

Last Name

Phone Number:

Email:

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If there are more than two people involved in the conflict/matter, please provide their information.

Brief description of the situation/conflict and why you requesting mediation:

Is there anything else you would like us to know, or any concerns you may have?

Referral Forms

Victim-offender Dialogue (VOD) Program

Restorative Dialogue & Mediation Request

Please fill out this form if you are a member of the community requesting a Restorative Dialogue or Mediation.

Navigate

Referral Forms
Donations
Events

Contact

office@sdrjmp.org
619 280 1993

In Cooperation With —

Referral Forms

Victim-offender Dialogue (VOD) Program

Restorative Dialogue & Mediation Request

Please fill out this form if you are a member of the community requesting a Restorative Dialogue or Mediation.

Navigate

Referral Forms DonationsEvents

Contact

office@sdrjmp.org 619 280 1993

In Cooperation With —

Referral Forms
Donations
Events

office@sdrjmp.org
619 280 1993