Eau Claire Restorative Justice Referral Form | ECRJ

Client Information:

First Name *

Middle Initial

Last Name *

Date of Birth: *

Primary Phone: *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Offense Date:

Case Number:

Gender:

Marital Status:

Race:

Have an additional race:YesNo

Ethnicity:Hispanic/LatinoNot Hispanic or Latino

Primary Language:

Primary Disability:

Secondary Disability:YesNo

Military Service:YesNo

Transportation:Drives own vehicleEverything Else

Criminal History:YesNo

School (if applicable):

Grade Level:

Highest Level of Education:

Work History:RegularLimitedNone

Currently Employed:YesNo

Hourly Wage:

Number of hours per week:

Parent/Guardian Information (if applicable):

Name:

Relationship:

Street Address (if different than above)

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone:

Email:

Client's Household Information:

Number in Household:

Are they receiving Public Benefits:YesNo

Referred By:

Name

Date of Referral:

Phone Number

Email:

Referral County:

Referred to Program

Referral Source:

Law Enforcement Agency:

School Name:

Please enter referral source:

Offense/Reason Referred:

Special Considerations:

Accomplices:

Has the Client been previously referred to Restorative Justice?YesNoUnknown

Attachments

Please attach all supporting documents such as Police Report, Deferred Agreement, Law Enforcement Referral, etc.

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Elevating People by Eliminating Barriers to Employment

Eau Claire County Restorative Justice

Referral Form