Peer Mediation Referral Form 2024-2025 SY
Welcome to Peer Mediation!  This is our 9th year having this program at MPMS.  Our Peer Mediation Program was established to help give students opportunities to resolve their own conflicts with the assistance of trained peer mediators.  We are excited to continue our program this school year!

Student:  please complete this form for yourself and another student (s) if you have a conflict and would like to resolve their issue.

School staff:  please complete this form for at least two students who have a conflict, and you would like for them to come resolve their issue.  
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Email *
Today's date
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Name of Referring Adult (if applicable)
Name of student 1 (yourself)
Grade level of student 1 ( or yourself)
Name of student 2 (other student involved)
Grade level of student 2
Conflict is about:  (check all that applies)
Place the conflict is happening:  (check all that applies)
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