Referral Form

or print the blank form, fill it out, and fax it to us,
or scan and send by an attachment through email to mediationwithsusan@gmail.com

Piedmont Mediation Center, Inc.
Fax: 980-939-7997              Office: 704-873-7624      

Youth name

Date of Birth



Referred by (name, phone & email)


Parent Mailing Address

Parent Email

Parent Phone (cell & home)

Programs Referred to (if you are not sure, we will work with you to figure out what is best):
Victim-Offender Conference ___       Incident Circle for Groups ___
Emergency Mediation ___     Truancy Mediation ___       2Young2Drink ____                           
Teen Court ___

Parent contacted?
Yes_____      Not yet _____
If Truancy is involved, days absent:
Excused ___ Unexcused ___ Tardies _____       

Required Questions
In your opinion, does this issue rise to the level of a crime? (Bullying, Communicating Threats, Assault, Damage to Property, Substance Abuse, Shoplifting?)
Yes ___

What is the risk level for repeat behavior?
Low    Medium   High

Will you pursue charges in Juvenile or District Criminal Court?
Yes ___

Are you diverting this issue from Juvenile Services or District Criminal Court through a successful process with Piedmont Mediation Center, Inc.?
Yes ___

Other Comments or Youth Involved (if Victim-Offender, we require the names of all involved parties)