Peer Mediation Referral Form

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Peer Mediation is a student-led conflict resolution program that is appropriate for low level interpersonal disputes, such as misunderstandings between friends, rumor spreading, or other relationship issues. Our goal is to rebuild student relationships before a small conflict runs the risk of escalating to a larger, more dangerous one. This is done using a restorative practices model of mediation. Any other types of conflicts or concerns (such as physical assaults, substance use) should be addressed directly to the Dean's office.

If you need immediate assistance or have further questions or concerns, contact the Equity and Social Justice Coordinator via email at lrivera57@schools.nyc.gov or visit Room 351 during periods 4, 5, and 6.

Email *

Referrer's First Name *

Referrer's Last Name *

Referrer's Email Address *

What is your current position? *

If your role it not outlined above, tell us your role here. *

Student 1 Last Name *

Student 1 First Name *

Student 1 OSIS Number

Student 2 Last Name *

Student 2 First Name *

Student 2 OSIS Number

Are there more than two students involved in the situation you are referring? *

Yes

Please describe situation/reason for referring these students to Peer Mediation *

Is this matter urgent? *

Yes (mediation will occur within 24 hours with concent from all parties involved)

No (mediation will occur within 24-72 hours with concent from all parties involved)

If you chose yes to the question above, please provide further details below as to why this matter is urgent. *

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