2850 College Drive, Rice Lake,
WI 54868
715-736-0940
REFERRAL FORM
Date rec’d: __________________ Date closed: _________________
Check appropriate box: Office use:
TEEN COURT case # _______
VICTIM OFFENDER CONFERENCE
RESTORATIVE TEEN COURT
VOC case #_______________ Date rec’d: ________________ Date closed: _________________
Referred By________________________________________
Phone #___________________________________________
Please include any of the applicable: victim statement, statement of loss, teacher statement, police report, any other pertinent information.
Offender Information (use separate form for each offender)
Name_____________________________________________________________________________________
Address___________________________________________________________________________________
Male______
Female______ Age or
DOB_____________ Home Phone Number________________________
Grade in school______________ Name of teacher (If in
elementary)________________________________
If under 18, parents/guardians names and
addresses_________________________________________________
_________________________________________________________________________________________
Names of other offenders in the
case____________________________________________________________
Were others referred to Victim-Offender Conferencing? Yes______ No______
Were others referred to Teen Court? Yes______ No______
Employer__________________________________________________________________________________
School____________________________________________________________________________________
Offense/s
_________________________________________________________________________________
Date of
Offense/s_____________________________
Was a citation Issued?______________________
Summary
of offense and nature of damages
Victim Information
(additional forms for
multiple victims)
Name_____________________________________________________________________________________
Address__________________________________________
Home Phone #___________________________
Male______
Female_______ Age or
DOB________________
Grade in school_________ Name of teacher (if
in elementary)____________________________
If under 18, parents/guardians names and
addresses________________________________________________
_________________________________________________________________________________________
Other victims: Yes______ No______
Were others referred to VOC or Teen Court: Yes_____ No______
*use attached multiple victims form
Names of
offender/s:_________________________________________________________________________
Do victim and offender know each other?
Yes_____ No_____
If
related, how___________________________________
Has anyone spoken to victim about
Victim-Offender Conferencing or Teen Court at this point?_______
If so, who:______________________
Additional information: