Welcome.

Please fill out the confidential form so we can connect you to the right person to speak with from the Billings Mediation Center.

Please Note: This form must be completed in one sitting. You may not save your work and return later to complete it.

School Contact

This helps us understand who submitted the referral. Please enter your name and contact information.

Name

First Name

Last Name

Role

Please select your role with the school

Phone

(###)

###

####

Are you a party to this matter?

Yes

I'm not sure.

Reason for referral

Please provide a short synopsis of the reason for referral. (approx. 350-500 words).

Security recommended

If security is recommended, please indicate any specific recommendations and/or reasoning.

Yes

I'm not sure

Security concerns

All parties will be together in one room. Please describe any safety concerns any party has about the situation.

Parties

Party 1 | Student Information

Please enter the involved Student information here first.

Student name | Student 1

First Name

Last Name

Student 1 Grade

Student Primary Parent/Guardian Name

At least one parent must be listed for each student.

First Name

Last Name

Student Primary Parent/Guardian Email

Student Primary Parent/Guardian Phone Number

(###)

###

####

Student Primary Parent/Guardian Name

(optional)

First Name

Last Name

Student Primary Parent/Guardian Email

(optional)

Student Primary Parent/Guardian Phone Number

(optional)

(###)

###

####

Party 2 | Student or Other Involved Party Information

This may be another involved Student, but may also be an involved Teacher, Counselor, School Staff, School Administrator, Fellow Student, Community Member, etc.

Party 2 | Role

Please select the role of this Party. If they are a fellow student, at least one Parent/Guardian's name MUST be provided. Otherwise, please leave these name blank.

Party 2 | Student or Other Party Name

First Name

Last Name

Party 2 | Student Grade

Party 2 | Primary Parent/Guardian Name

At least one parent must be listed for each student.

First Name

Last Name

Party 2 | Primary Parent/Guardian or Other Party Email

Party 2 | Primary Parent/Guardian or Other Party Phone Number

(###)

###

####

Party 2 | Additional Parent/Guardian Name

First Name

Last Name

Party 2 | Additional Parent/Guardian Email

Party 2 | Additional Parent/Guardian Phone Number

(###)

###

####

Party 3 | Student or Other Involved Party Information

This may be another involved Student, but may also be an involved Teacher, Counselor, School Staff, School Administrator, Fellow Student, Community Member, etc.

Party 3 | Role

Please select the role of this Party. If they are a fellow student, at least one Parent/Guardian's name MUST be provided. Otherwise, please leave these name blank.

Party 3 | Student or Other Party Name

First Name

Last Name

Party 3 | Student Grade

Party 3 | Primary Parent/Guardian Name

At least one parent must be listed for each student.

First Name

Last Name

Party 3 | Primary Parent/Guardian or Other Party Email

Party 3 | Primary Parent/Guardian or Other Party Phone Number

(###)

###

####

Party 3 | Additional Parent/Guardian Name

First Name

Last Name

Party 3 | Additional Parent/Guardian Email

Party 3 | Additional Parent/Guardian Phone Number

(###)

###

####

Additional Information

Please provide any additional information that may be helpful in allowing us to best serve you.

Welcome.

Please fill out the confidential form so we can connect you to the right person to speak with from the Billings Mediation Center.

School Contact

levelheaded