Peer Mediation Request
***Mediation sessions are held during CLIMB time or scheduled times (if needed). Please contact Mrs. Geer if you have any questions.
Date of Request
/
Month
/
Day
Year
Date
Name of Student 1
First Name
Last Name
Name of Student 2
First Name
Last Name
Mediation Requested By:
Student
School Counselor
Teacher
Administration
Other School Staff Member
Incident Regarding (Check all that apply):
Friendships
Romantic Relationships
Social Media
Verbal Harassment (name-calling, teasing, etc.)
Physical Fighting
Property/Money/Goods
Rumor/Gossip
Other
Describe the Conflict:
Submit
Should be Empty: