Peer Mediation Referral Form
If you have a problem at school with another student, fill out this form and submit it. The Baker peer mediators will schedule a mediation and help you and the other student talk and come up with a resolution. Please note that all entries can be traced to your source computer or device.
Today's date
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Name of person making referral
Your answer
Person making referral is:
Place of conflict: check all that apply
Required
Disputant #1 NAME (first and last name of person having or causing problem)
Your answer
Disputant #1 GRADE
Disputant #2 NAME (first and last name of person having or causing problem)
Your answer
Disputant #2 GRADE
Explain the conflict: the more details, the better
Your answer
Any other comments or notes:
Your answer
Submit
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