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2. School-Based Restorative Justice Referral Form
4. Criteria for Restorative Justice Practices Referral

   This information is intended to guide referring parties in making decisions about appropriate referrals to a Restorative Justice (RJ) process. Once a referral is made, it is the responsibility of the Juvenile Services Restorative Justice team to make the final assessment of case suitability.

   Participating in a Restorative Justice process is voluntary for all parties.

   Parent permission is required to participate in a Restorative Justice process.

   • Referring parties should secure parent permission prior to making the referral.
   • Referring parties may seek support from the Juvenile Services Restorative Justice team when securing parent permission and/or discussing the Restorative Justice process.

   The offending student(s) must admit involvement in the incident.

   • There are differing degrees of responsibility in an incident of wrongdoing; however, the student(s) must admit to being involved in the incident.

   There should be clear evidence to support that wrongdoing has occurred.

   • The process is not meant to be used as an investigative method for determining guilt.
   • If the offending student(s) and those harmed by the wrong doing agree that there has been a violation and harm has been done, but they can’t determine or won’t acknowledge who is responsible for what, a conference can help sort out specific acts and responsibility for those actions—but the offending student(s) referred for the process must admit to being involved in the wrongdoing.

   Every student should have access to Restorative Justice and be considered for referral.

   • Every GWSD student must have access to a Restorative Justice process. Offending students must admit involvement in the wrongdoing to access the Restorative Justice process.
   • Students who receive services from a school social worker, school psychologist, or medical professional always have the option to include that person or persons with them in the RJ process as supporters.

   Prior offenses do not preclude a student from being referred to a RJ process.

   • Often students do not understand the impact of their actions. Students can benefit from a RJ process, even if a prior history of wrongdoing is evident.

   All incidents of wrongdoing and violations of GWSD rules are eligible to be referred.

   In an RJ process, everyone adversely affected by the wrongdoing is a harmed person.

   • This includes participating students and their families.

   Referrals can be made at all stages of the disciplinary process and for almost every incident or wrongdoing, regardless of the seriousness of the offense.

   • Referral can be made as a diversion from the traditional disciplinary process for appropriate situations.
   • Restorative Justice can be utilized in combination with other discipline actions such as: one-day suspension and referral to RJ, as opposed to 3-10-day suspension. This option work well for fighting and verbal altercations when both students admit involvement.
   • A Restorative Justice process can be initiated for re-entry into the classroom or school after a disciplinary action has been completed. Ample time prior to re-entry is needed.
   • A referral to an RJ process should not be used as an additional punishment or sanction for the offending student(s).

   This document has been adapted from Fairfax Public Schools: https://www.fcps.edu/sites/default/files/media/forms/RJInformationPacket.pdf

6. I have read and understood the criteria above.*
10. Primary Contact Info: (Referring party/ Adult Witness/ Adult Victim):
12. Name:
13. School:
15. Teacher's Name:
16. Phone:
18. Email Address:
22. Issue, concern or dispute:
    -- Select One --FightingBullyingVerbal HarassmentSexual HarassmentThreatProperty DamageOther
24. If Other, write below:
26. Date of Incident Occurrence:
    Date of Incident Occurrence:
30. Responsible Youth Information:
32. Name:*
33. Grade:*
34. Age:*
36. Does youth take at least some responsibility in being involved? *

    1. Yes
    2. No
38. Explain:*
40. Parental consent:*

    1. Yes
    2. No
42. Additional Responsible Youth(s):
44. Name:
45. Grade:
46. Age:
48. Name:
49. Grade:
50. Age:
54. Impacted Youth:
56. Name:*
57. Grade:*
58. Age:*
60. Parental consent:*

    1. Yes
    2. No
62. Additional Impacted Youth:
64. Name:
65. Grade:
66. Age:
68. Name:
69. Grade:
70. Age:
74. Brief Description of Incident:*
76. What would you like to see happen to resolve this issue?:
78. What interventions have already taken place because of this? (Court case/complaint, ISS/OSS):
80. What interventions may take place without engagement in Restorative Process?:
84. Scheduling:
86. Date of Referral:
    Date of Referral:
88. Response Requested By:
    Response Requested By:
90. Gunnison County Juvenile Services will respond to your referral within 24 to 48 hours, excluding weekends and holidays.
Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

* indicates a required field