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

- 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*

- 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
- Should be Empty: