Formal Restorative Circle Feedback Form 
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Participant Name (OPTIONAL) 

Date of restorative circle (OPTIONAL)

MM
/
DD
/
YYYY
School/Office 

 *
Name of Circle Facilitator

 *
Was a plan of action discussed or developed to provide follow-up support (e.g. commitment to safety, action plan, collaborative agreements, proposed solutions, etc.)?  *
What was the purpose for the mediation/circling? CHECK ALL THAT APPLY. *
Required
To what extent do you agree with each of the following statements?
 *
Strongly agree
Agree
Disagree
Strongly disagree
I felt heard during the conversation.
The process was clearly communicated with you.
I felt informed throughout the process.
The facilitator was an active listener.
The facilitator demonstrated fairness and impartiality.
The facilitator demonstrated the ability to earn trust and maintain credibility.
I am satisfied with the results of the mediation.
Any comments or suggestions about the mediator or the mediation process? Your feedback is valued.    
Is there any specific follow-up you'd like to request? If so, briefly explain below and include your name, so we can connect with you.
Thank you for sharing your feedback. If you feel that there is anything that remains unresolved or that any additional follow-up needed, please reach out to your RA circle facilitator. 
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