Tri-County Community Corrections

TRI-COUNTY COMMUNITY CORRECTIONS Restorative Justice Referral Form

______Juvenile Victim Empathy Program (Classes) (Six-session course) ______Restorative Justice (Mediated Conference) (Pre-sessions individually then a mediated conference. Victim-Offender focus) ______Family Group Conferencing (Pre-sessions individually then a mediated conference. Family focus) ______Prep for Change (Chemical Education) (Four-session course) ______Girls Group (Number of session can be determined) ______Pride Days (Using peer mentoring) (Serves 7th, 8th and 9th grades using senior peer mentoring) ______Senior Peace Team Meetings (Senior class meets once a month to discuss school climate to reduce harassment) ______Elementary Peace Curriculum (4-6 sessions meeting once a week in circle format to discuss communication, self-esteem and culture) ______Truancy Tracking and Family Group Conference (Family Group Conferencing involving School, Juvenile and Parent) ______General Prevention (Individual sessions using materials gathered from above classes to serve children who don’t fit well in groups or need extra support) ______General Education or Peace Keeping in Circle format (One or more mediations w/groups of 4 or more to discuss harms caused) ______IEP Meetings (Can attend meetings if involved w/a child or can help facilitate meeting) ______Social Skills or Life Skills Classes (Presentations and Groups to supplement Health or Career Classes)

Court Ordered yes or no(Circle one) School Referral yes or no(Circle one)

Referral Agency:______Contact Information:______

Referred by:______Title:______

Approved By:______Title:______

Date of Referral:______Parental Consent Signed? Yes or No (Circle one) Courts Please Complete

Juvenile’s Name: ______File # ______DOB: (Please Print)

Parent(s) Name: ______Address: ______City/State/Zip: ______Home Phone #: ______Work Phone #: ______

Juvenile Resides with ______

Offense(s): ______Date of offense ______

Does Court require Restorative Justice Status? Yes or No (Circle one) By what date? ______Complaint enclosed in Referral? Yes or No (Circle one) Any modifications needed: ______Probation Agent: ______Date: ______Victim/s name: ______Victim’s phone______Victim/s Parent/Guardian name:______Victim’s Mailing Address: ______

For Restorative Justice Staff Only:

Entered into Master log: ______Services received on:______

Successfully Completed Program On: ______

Failed to Complete Program On: ______Reason:______

Letters of Completion Sent On: ______Cc: RJ File Copy Cc: Master File Date Received Stamp: Schools or Agencies Please Complete

Juvenile’s Name: ______Grade:______

DOB: (Please Print)

Harm Caused or Concerns:______Date of Harm Caused:______Student(s) or People Involved:______

______

Staff Involved: ______Contact Information:______

Does School/Agency Require Status of Referral? Yes or No By what date? ______Any modifications needed:______

Best time/date/location to see child is:______

Times/dates/locations the child is unable to be seen is:______

For Restorative Justice Staff Only: Services approved by:______Date:______

Entered into Master log: ______Services Received on:______

Successfully Completed Program On: ______

Failed to Complete Program On: ______Reason:______

Letters of Completion Sent On: ______Cc: RJ File Copy Cc: Master File Date Received Stamp: ______Tri-County Community Corrections Restorative Justice Program Professional Bldg., Suite 30 223 East 7th Street Crookston, MN 56716 TRI-COUNTY COMMUNITY CORRECTIONS Please have parent/guardian complete the next two pages. Dear Parent/Guardian,

Tri-County Community Corrections, Restorative Justice Program has been funded through Local Children’s Collaborative and the Safe Schools Grant. Due to new funding changes and not being an agent under the schools, a Consent to Participate and Releases of Information needs to be signed before providing Restorative Justice Programming within the schools and outside agencies. Should you have any further questions please contact, Shelby Reitmeier at (218) 281-9674 or email [email protected].

I thank-you for your time and cooperation.

Sincerely,

Shelby Reitmeier

Parent/Guardian Please fill out the following two pages.

Child’s Name:______Parent Contact Information Parent(s) Name: ______Address: ______City/State/Zip:______Home Phone #______Work Phone #: ______Juvenile Resides with: ______

Would you like the Restorative Justice Department to notify you after services have been provided? Yes or No

Do you grant permission to leave messages on your phone numbers given above? Yes or No

Parental Consent to Participate in the Restorative Justice Program

I ______, parent and/or legal guardian of______, (Parent/Guardian Name) (Child’s Name) give authorization for ______to participate in the Restorative Justice (Child’s Name) Program offered by Tri-County Community Corrections for the sole purpose of aiding the school or agencies the referral is received from. Tri-County Community Corrections will maintain confidentiality as long as the child presents that he/she is in no imminent danger and will not harm themselves or someone else. This authorization is granted to serve the above named child for no longer than one year from the date signed. ______Parent’s Signature Date

TRI-COUNTY COMMUNITY CORRECTIONS Restorative Justice Release of Information Form

I authorize Tri-County Community Corrections Restorative Justice Program to Release and Obtain pertinent information with: ____Public/Private Schools:______County Social Services including any pertinent file records as indicated below:______Tri-County Community Corrections, Probation Department ______Person/Agency and Address:______Person/Agency and Address:______Person/Agency and Address:______Law Enforcement:______

Information to be obtained and released: ____School Records (including behavioral evaluations) ____Health/Medical Records ____Psychological/Psychiatric Records ____Chemical Dependency Evaluations and Reports ____Probation Information ____Any other pertinent information Other______

The intent of this request is to provide Restorative Justice Services as indicated on the referral form.

I understand this authorization is effective from______, until termination of services with Tri-County Community Corrections Restorative Justice Program which is not to exceed one calendar year from today’s date. I further understand that upon my written request I may terminate/change this authorization/release at any time.

Parent / Guardian Signature:______Date:______Parent / Guardian Signature:______Date:______

______Tri-County Community Corrections Restorative Justice Program Professional Bldg., Suite 30 223 East 7th Street Crookston, MN 56716