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Peer Mediation Referral Form
* Indicates required question
Email
*
Record my email address with my response
Today's Date
*
MM
/
DD
/
YYYY
Name of Student in Conflict (Include self, if involved)
*
Your answer
Name of Other Student(s) in Conflict
*
Your answer
Briefly describe the conflict
*
Your answer
How long has the conflict been an issue?
*
1-3 Days
4-7 Days
1-2 Weeks
2-4 Weeks
Over 1 Month
Are both parties aware that they have been referred for a mediation?
*
Yes
No
Maybe
Mediation requested by:
*
Administrator
Counselor/Social Worker
Peer mediator
Teacher
Student
Parent
Other:
I affirm that the above information is submitted with honesty and the best intentions. It is submitted with hope that the conflict can be resolved in a peaceful manner.
*
yes
No
Required
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