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Circle or Mediation Referral Form
Email *
Is this a request for circle (RJ), a conflict mediation, or student teacher conflict meeting? *
First Student's Name (last, first)? *
First Student's Grade?
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First Students Identification Number?
Second Student's Name (last, first)?
Second Student's Grade?
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Second Student's Identification Number?
Are there other students involved who should be contacted? *
Who are the other students?  Please provide names and identification numbers if available (last, first - ID).
Briefly describe why you are requesting a circle or conflict mediation.
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