Peer Mediation Referral Form 2025-2026 SY
Welcome to Peer Mediation!  We are excited to continue our Peer Mediation Program this school year.  The goal of our Peer Mediation Program is to give students opportunities to resolve their own conflicts with the assistance of trained peer mediators. This can also reduce their referrals to the office.

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 resolve their issue.  
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 *
The conflict is about this.  *Only pick ONE. *
Location where the conflict is happening the MOST. *Only pick ONE. *
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