2850 College Drive, Rice Lake, WI 54868

715-736-0940

STATISTICAL FORM

Offender Name:

Case #

Today’s Date:

Intake Date:

Was Victim/Offender Conference Held? Yes No

Victim willing? Yes No

Offender willing? Yes No

Pre-conference victim? Yes No

Pre-conference offender? Yes No

Was it already resolved? Yes No

Did victim want restitution only? Yes No

Was an agreement reached? Yes No

Date conference was held:

Location of the conference:

If juvenile, were offender’s parents present? Yes No

Relationship between the victim(s) & offenders prior to incident:

1. Knew each other Yes No

2. Related Yes No

Was this the first conflict between parties? Yes No

Number of participants:

Number of victims:

Number of offenders:

Number of others involved:

Agreement Information

Amount of $ restitution:

Behavioral? Yes No Explain:

Number of Community Service hours:

Number of personal service hours:

Apology? Yes No Verbal Written

Date agreement to be completed:

Date closed:

Closure information Successful Unsuccessful N/A

Mediator Information

Name: Hours: Name: Hours:

Phone H: W: Phone H: W:

Demographics (Please use numbers not x’s)