Restorative Justice Referral Form

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Restorative Justice Referral Form - Gardena High School

This form helps identify the need for support and goes directly to Mr. Ponferrada, our Restorative Justice Teacher. Fill out as much as possible. All information will be kept confidential as much as reasonably possible.

Email *

Priority *

Low (schedule when available)

High (schedule as soon as possible)

Emergency (see now)

Date *

YYYY

Referred By: *

Teacher

Parent

Self

Other (please specify)

Student Name(s): *

Grade: *

Have You Contacted Parent/Guardian About Your Concern?

Yes

Clear selection

Date of Parent/Guardian Contact

YYYY

Name of Parent/Guardian Contacted

Reason(s) for Referral; Issues/Concerns Related to: *

Dramatic change in behavior

Worries

Grief

Fatigue/Always tired

Lack of Motivation

Inattentive

Withdrawn

Cries Easily/Often

Self-Image/Lack of Confidence

Nervous/Anxious

Aggression/Anger

Fighting

Bullying

Disrespectful/Defiant

Self-Harm

Impulsive

Other:

Required

Clarify Referral Issue/History *

Actions Taken by Person Referring

Other Service(s) Student is Receiving

Submit

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