or print the blank form, fill it out, and fax it to us,
or scan and send by an attachment through email to firstname.lastname@example.org
Piedmont Mediation Center, Inc.
Fax: 980-939-7997 Office: 704-873-7624
Date of Birth
Referred by (name, phone & email)
Parent Mailing Address
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 ___
Yes_____ Not yet _____
If Truancy is involved, days absent:
Excused ___ Unexcused ___ Tardies _____
In your opinion, does this issue rise to the level of a crime? (Bullying, Communicating Threats, Assault, Damage to Property, Substance Abuse, Shoplifting?)
What is the risk level for repeat behavior?
Low Medium High
Will you pursue charges in Juvenile or District Criminal Court?
Are you diverting this issue from Juvenile Services or District Criminal Court through a successful process with Piedmont Mediation Center, Inc.?
Other Comments or Youth Involved (if Victim-Offender, we require the names of all involved parties)