Mediation Referral
Type of referral:
*
Please Select
Restorative Practices
Juvenile Justice
Child Welfare
Excessive Absenteeism/Truancy
Other
Other referral type
Referred by:
*
Please Select
Government Agency/Org: Law Enforcement
Government Agency/Org: Diversion Program
Government Agency/Org: Probation
Attorney: City Attorney's Office
Attorney: County Attorney's Office
Attorney: Public Defender
Court: County
Court: District
Court: Juvenile
School
Other
Other referred by
*
Referral Source
Referrer Organization:
*
Name of Referrer:
*
First Name
Last Name
Referrer Contact Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Participant(s)
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I agree to accept texts at this number
*
Yes, please
No, thank you
Email
*
example@example.com
I regularly check this email
*
Yes, I do
Sorry, I do not
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the participant a juvenile?
*
Yes
No
Parent/Guardian Name
*
First Name
Last Name
Parent / Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I agree to accept texts at this number
*
Yes, please
No, thank you
Parent / Guardian Email
*
example@example.com
I regularly check this email
*
Yes, I do
Sorry, I do not
Are there additional individuals involved in causing the situation?
*
Yes
No
Other Participants
*
Do any parties involved require an interpreter:
*
Please Select
Yes
No
Unknown
Language
*
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Youth Details
School Status
*
Please Select
Not Enrolled
Enrolled
In-school Suspension
Out-of-school Suspension
Expelled
School District
*
Please Select
Alliance Public Schools
Arthur County Schools
Banner County Public Schools
Bayard Public Schools
Bridgeport Public Schools
Chadron Public Schools
Crawford Public Schools
Creek Valley Schools
Educational Service Unit 13
Educational Service Unit 16
Garden County Schools
Gering Public Schools
Gordon-Rushville Public Schools
Hay Springs Public Schools
Hemingford Public Schools
Hyannis Area Schools
Kimball Public Schools
Leyton Public Schools
Minatare Public Schools
Mitchell Public Schools
Morrill Public Schools
Mullen Public Schools
Ogallala Public Schools
Paxton Consolidated Schools
Pine Ridge Job Corps School District
Potter-Dix Public Schools
Scottsbluff Public Schools
Sidney Public Schools
Sioux County Public Schools
South Platte Public Schools
Homeschool registered with the State of Nebraska
Private school or other public school not listed
Grade in School
*
Please Select
Infant (6weeks to 18 mos. Old)
Toddler (age 18 months to 3 years)
Preschooler (age 3 to Kindergarten)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Post-12th grade state services
Higher Education
Other
Other grade in school
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Student's Employment Status
*
Please Select
Not Employed
Employed - Full Time
Employed - Part Time
Other
Other employment status
*
Current Residence of Youth
*
Please Select
ONE PARENT - youth lives with only one of his/her biological parent
TWO PARENTS / JOINT PHYSICAL CUSTODY - youth lives with both biological parents OR one biological parent & another custodial parent OR spends time with both parents in separate homes under a joint custody agreement
LEGAL GUARDIAN - youth lives with a legal guardian
RELATIVE / OTHER ADULT - youth lives with an extended family member OR another adult who is not a legal guardian.
LIVES ON OWN - youth lives independently
GROUP SETTING - youth lives in a detention OR foster OR group home
OTHER - out of home placement
Other Residence
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Family Size (primary residence):
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Household Income Threshold
Is the household income for the youth's primary residence at or below ${householdIncome75}?
*
Yes
No
Gender
*
Please Select
Female
Male
Female Trans
Male Trans
Non-binary
Not Reported
Other
Other Gender
*
Race
*
Please Select
Native American / Indigenous or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
Unknown
2 or more races
Other Race
*
Ethnicity
*
Please Select
Not Hispanic
Hispanic
Latino
Latinx
Unknown
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About the Situation
Briefly describe the outcome you hope to see from this mediation referral.
*
Is this there a case in court associated with this referral?
*
Yes
No
Unsure
In which County is your case filed?
*
Please Select
Arthur
Banner
Box Butte
Cheyenne
Dawes
Deuel
Garden
Grant
Hooker
Keith
Kimball
Morrill
Scotts Bluff
Sheridan
Sioux
Another County in Nebraska
Outside of Nebraska
Not Sure
Court Case Number
*
(For Example: JV24-01)
Consent to Mediate Signed Document(s):
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If you or your office have signed consent forms for this process please include here where possible.
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