Victim Request Form

Eau Claire County Restorative Justice

First and Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

How do you prefer to be contacted?

Home PhoneHome Phone

Mobile PhoneMobile Phone

EmailEmail

Date of Offense

Was the incident reported to authorities?

OffenseOffense

Please provide a brief summary explaining the nature of the offense:Please provide a brief summary explaining the nature of the offense:

What do you hope to gain from a Victim Offender Conference?What do you hope to gain from a Victim Offender Conference?

How did you hear about the Restorative Justice Program?How did you hear about the Restorative Justice Program?