Name *

First Name

Last Name

Phone *

(###)

###

####

Do you require an interpreter?

Yes

No

Have you previously participated in restorative justice? *

Yes

No

Are there any current safety concerns for yourself or others involved? *

Yes

No

Are there any past or present experiences with violence, abuse, or coercion that may affect your participation? *

Yes

No

Do you currently receive support for mental health? *

Yes

No

I would like support

Have you ever received a mental health diagnosis?

Yes

No

Are you currently experiencing:

Please check all that apply

Suicidal thoughts

Self-harm behaviours

Difficulty managing strong emotions

Flashbacks or dissociation

N/A

Do you feel ready to talk about the incident? *

Yes

No

Maybe

Do you have supportive people you can turn to?

Please check all that apply

Family

Friends

Counsellor

Community or cultural supports

No one at this time

Would you like someone to accompany or support you in the process? *

Yes

No

Not Sure

Are there cultural, spiritual, or community-based practices that are important for you to include in this process? *

Yes

No