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Peer Mediation Referral
Use this form to initiate the peer mediation process.
Email address
Type of Referral
Name of Person Making The Referral
Your answer
Are you involved in the conflict?
Does the conflict involve any of the following?
Please note that Peer Mediators cannot mediate matters involving drugs, weapons, or the physical/sexual abuse of a student. These matters will be shared with the proper agents who will intervene as appropriate.
Name of Student 1
Your answer
Lunch Period of Student 1
After School Availability of Student 1
Name of Student 2
Your answer
Lunch Period of Student 2
After School Availability of Student 2
Brief description of the conflict
Your answer
Date of the original conflict
MM
/
DD
/
YYYY
Other related information
Your answer
If they are known, please include the email addresses of the parties we need to contact to set up the mediation. We will reach out to you to arrange a time within 3 days of the referral.
Please complete the captcha before submitting the form.
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