C.A.R.E Circle Request Form

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This request will be sent to the Justice Coordinator to conduct a pre-conference to discuss the incident more in depth individually with all parties involved, to make sure everyone is comfortable, willing, and prepared to participate in the circle process. Once the CARE Practitioner speaks with all the parties involved next steps in the process will be discussed.

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Name

Your Role

Student

Staff

Parent/Guardian

Other:

Clear selection

Reason for Request

Please describe your situation, including the names of individuals involved and related issues or themes. Indicate any immediate needs.

Do you want to be a part of the circle?

Yes

Clear selection

If yes to previous question, when are you available for a circle? Be as specific as possible. (Ex: Monday from 9-11, Tuesday 12-3)

Do you want to be updated on progress/outcome?

Yes

Clear selection

Choose preferred response time

Needs immediate action before the days end

Within 24 hours

Within 2 to 3 days

Before the end of the week

Anytime within the next 1 to 3 weeks

Other:

Clear selection

Contact information

Best times to reach you

Submit

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