Restorative Justice Unit Referral Form - I am the person harmed (victim)

Contact information
Name*

First NameLast Name
Preferred name
Date of Birth*

DayMonthYear
Are you of Aboriginal or Torres Strait Islander origin?*

Yes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal and Torres Strait IslanderNoPrefer not to say
Phone Number*

Area CodePhone Number
Email*
Enter a valid email address
Postal Address*
Preferred method of communications*

PhoneEmail
Are you under 18 years old?*

YesNo
Name of a responsible adult*

First NameLast Name
Relationship to responsible adult*
Responsible Adult Phone Number*

Area CodePhone Number
Responsible Adult Email*
Enter a valid email address
Responsible Adult Postal Address*

The offender’s details (the person who caused you harm)
Please provide as much information as possible about the person who caused you harm.
Offenders name

First NameLast Name
What was the offence/s*

0/300
Your relationship to the offender (the person who caused you harm)
Is this matter related to family and domestic violence?*

NoYes
Does this referral relate to a pre-sentence or post-sentence court procedure?

pre-sentencepost-sentence
The pre-sentence phase occurs after a defendant has been found guilty or has pleaded guilty to an offence, but before the court delivers its final sentence.

The post-sentence phase refers to the period after an offender has been sentenced.
Next court date

DayMonthYear
Sentence end date

DayMonthYear
Please confirm you are human by writing what you see in the image in the box below*
Form-type*
Date

DayMonthYear
Date
Hour Minutes
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