Make Amends Schools Referral Form

School Referral Form

Referral telephone number 01803 222033
Date

MonthDayYear
Date
School Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referrer Contact

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Name of person taking responsibility for the harm:*

First NameLast Name
Date of birth

MonthDayYear
Date
Phone number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are these considered safe contact details? If not, please provide more information:
Does this person have a Social Worker? (please provide name and contact if applicable)
Is this person subject to the following?

MAPPAMARACPPO
Is a full risk assessment required for this person?

YesNo
Does this person take accountability / accept responsibility for the harm caused? (if no, restorative justice not likely to be suitable or effective, and we will not be able to proceed with the referral)*

YesNo
What would this person like to achieve/see as an acceptable outcome?
Has Consent to share information been given? *(if no, we may not be able to proceed with the referral - please see end notes)*

YesNo
Is there a preference for a male or female practitioner?

NoMaleFemale
Main offence/ Details of harm caused
Date Occurred

MonthDayYear
Date
Brief description of specific harm / damage caused:
Brief description of what happened:
Crime number (if applicable) and any license conditions/ restraining order/ non-molestation order
Name of person harmed*

First NameLast Name
Date of birth

MonthDayYear
Date
Phone number

Area CodePhone Number
Email address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are these considered safe contact details? If not, please provide more information:
Does this person have a Social Worker? (please provide name and contact if applicable)
What would this person like to achieve/see as an acceptable outcome?
Has Consent to share information been given? *(if no then we may not be able to proceed with the referral - please see end notes)*

YesNo
Is there a preference for a male or female practitioner?

NoMaleFemale
Do you consider there to be any reason we cannot or should not contact any named parent/guardian in this referral?*

YesNo
If so, why?
Signature

Clear
Notes on completion

You MUST have consent from BOTH parties and their respective parent/guardian.

N.B. Sensitive and Complex cases may be subject to a multi-agency meeting.
Should be Empty:

School Referral Form

Main offence/ Details of harm caused